Survey

Version 5010/ICD-10 Industry Readiness Assessment

Documents and Forms

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

Information Collection (IC) Details

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:

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 %

	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

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.