Information Collection

CHIPRA PQMP Candidate Measure Submission Form

IC 204286 under ICR 201209-0935-002 · OMB 0935-0205.

Documents and Forms

Document Name Document Type
Form Form #1 CHIPRA PQMP Candidate Measure Submission Form Form and Instruction
Form #1 CHIPRA PQMP Candidate Measure Submission Form Attachment A -- CHIPRA PQMP Candidate Measure Submission Form.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	CHIPRA PQMP Candidate Measure Submission Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	Form #1	CHIPRA PQMP Candidate Measure Submission Form	Attachment A -- CHIPRA PQMP Candidate Measure Submission Form.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 75	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	75	75
Annual IC Time Burden (Hours)	244	244
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.