OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

Nursing Home Quality Improvement Questionnaire

IC 201264 under ICR 201202-0938-006 · OMB 0938-1165.

Documents and Forms
Document Name
Document Type
Other-Information Sheet
Other-Follow-up Postcard
Other-CMS Invitation Letter
Form and Instruction
Form and Instruction
Information Collection (IC) Details

View Information Collection (IC)

Nursing Home Quality Improvement Questionnaire
 
No New
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Other-Information Sheet Questionnaire Information Sheet [rev 02-10-2012].docx No No Printable Only
Form and Instruction CMS-10366 Hard Copy - Nursing Home Quality Improvement Questionnaire QI Questionnaire [rev 02-10-2012].docx Yes No Fillable Printable
Form and Instruction CMS-10366 Screen Shots - Nursing Home Quality Improvement Questionnaire 5378 - Screen Shots_1-27-12.ppt Yes Yes Fillable Printable
Other-Follow-up Postcard Followup Post Card [rev 02-10-2012].docx No No Paper Only
Other-CMS Invitation Letter CMS Invitation Lette [rev 02-10-2012].docx No No Paper Only

Health Health Care Services

 

4,200 0
   
State, Local, and Tribal Governments
 
   50 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 2,100 2,100 0 0 0 0
Annual IC Time Burden (Hours) 693 693 0 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
No associated records found
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.