Information Collection

PPS-exempt Cancer Hosptital Quality Reporitng (PCQR) Program

IC 202342 under ICR 201209-0938-004 · OMB 0938-1175.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1175 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10431 PPS-exempt Cancer Hosptital Quality Reporitng (PCQR) Program	Form and Instruction
CMS-10431 Notice of Participation PCHQR.NOP.Aug_26_2012.rvised.V1.0.docx	Form and Instruction
CMS-10431 Data Accuracy and Completeness PCHQR.DACA form.Aug_27_2012.docx	Form and Instruction
CMS-10431 HAI Exception HAI Exception_Paper Form Aug_27_2012.docx	Form and Instruction
CMS-10431 Decline to Participate PCHQR.DeclineParticipation.Aug_26_2012_.docx	Form and Instruction
CMS-10431 Withdrawal Withdrawalform.Aug_26_2012_.docx	Form and Instruction

IC Title:

PPS-exempt Cancer Hosptital Quality Reporitng (PCQR) Program

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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
Form and Instruction	CMS-10431	Notice of Participation	PCHQR.NOP.Aug_26_2012.rvised.V1.0.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10431	Data Accuracy and Completeness	PCHQR.DACA form.Aug_27_2012.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10431	HAI Exception	HAI Exception_Paper Form Aug_27_2012.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10431	Decline to Participate	PCHQR.DeclineParticipation.Aug_26_2012_.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10431	Withdrawal	Withdrawalform.Aug_26_2012_.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 11

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: 100 %

table that charts list of burden
	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	27,273	27,273
Annual IC Time Burden (Hours)	68,182	68,182
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.