Information Collection

Nursing Home Quality Improvement Questionnaire

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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Questionnaire Information Sheet [rev 02-10-2012].docx	Other-Information Sheet
Followup Post Card [rev 02-10-2012].docx	Other-Follow-up Postcard
CMS Invitation Lette [rev 02-10-2012].docx	Other-CMS Invitation Letter
CMS-10366 Hard Copy - Nursing Home Quality Improvement Questionnai QI Questionnaire [rev 02-10-2012].docx	Form and Instruction
CMS-10366 Screen Shots - Nursing Home Quality Improvement Question 5378 - Screen Shots_1-27-12.ppt	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	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

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 4,200

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 50 %

table that charts list of burden
	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	2,100	2,100
Annual IC Time Burden (Hours)	693	693
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.