Information Collection

Survey

IC 198380 under ICR 201303-0938-006 · OMB 0938-1149.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10381 Survey	Form
CMS-10381 CMS-10381.Appendix C Respondent Letters Version 5010 ICD CMS-10381.Appendix C Respondent Letters Version 5010 ICD10 Readiness Assessment.pdf	Form
CMS-10381 Appendix D1 ICD 10 industry readiness assessment questio CMS-10381.Appendix D1 ICD 10 industry readiness assessment questionnaire 2012 09 26.doc	Form and Instruction
CMS-10381 Appendix D2 ICD 10 readiness assessment questionnaire fo CMS-10381.Appendix D2 ICD 10 readiness assessment questionnaire for post deadline fielding 2012.09.26.docx	Form and Instruction

IC Title:

Survey

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	CMS-10381	CMS-10381.Appendix C Respondent Letters Version 5010 ICD10 Readiness Assessment	CMS-10381.Appendix C Respondent Letters Version 5010 ICD10 Readiness Assessment.pdf	Yes	No	Fillable Fileable
Form and Instruction	CMS-10381	Appendix D1 ICD 10 industry readiness assessment questionnaire	CMS-10381.Appendix D1 ICD 10 industry readiness assessment questionnaire 2012 09 26.doc	Yes	No	Fillable Fileable
Form and Instruction	CMS-10381	Appendix D2 ICD 10 readiness assessment questionnaire for post deadline fielding	CMS-10381.Appendix D2 ICD 10 readiness assessment questionnaire for post deadline fielding 2012.09.26.docx	Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,200

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	1,200	600	600
Annual IC Time Burden (Hours)	204	54	150
Annual IC Cost Burden (Dollars)	0	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.