PPS-exempt Cancer Hosptital Quality Reporitng (PCQR) Program

PPS-exempt Cancer Hospital Quality Reporting (PCHQR) Program

OMB: 0938-1175

IC ID: 202342

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Document Name Document Type
Form CMS-10431 PPS-exempt Cancer Hosptital Quality Reporitng (PCQR) Program Form and Instruction
CMS-10431 Oncology Care Measures Online Data Entry Tool Data collection Feb_7_2013.Oncology Care Measures.pdf Form and Instruction
CMS-10431 Surgical Care Improvement Online Data Entry Tool Data collection Feb_7_2013.SCIP.pdf Form and Instruction
CMS-10431 Surgical Care Improvement Paper Submission Data Collection.Paperbased form.SCIP.Feb_08_2013.pdf Form and Instruction
CMS-10431 Oncology Care Paper Submission Data collectionFeb_8_2013.Oncology Care Measures.Paper Form.pdf Form and Instruction
CMS-10431 Extroadinary Circumstances/Disaster Extension or Waiver ExtraordinaryCircumstance Waiver.Application.Jan_16_2013.pdf Form and Instruction
CMS-10431 Extroadinary Circumstance Paper Form ExtraordinaryCircumstance Waiver.Paper submission.Feb_8_2013.pdf Form and Instruction
CMS-10431 Measure Exception Form Measure Waiver.Feb_8_2013.pdf Form and Instruction
CMS-10431 Notice of Participation Paper Form NoP Paper Form.April_26_2013.docx Form and Instruction
CMS-10431 Data Accuracy and Completeness Agreement PCHQR.DACA form.Paper.Feb_8_2013.pdf Form and Instruction
CMS-10431 Data Accuracy and Completeness Agreement Screen Shot PCHQR_DACA Application March_11_2013.pdf Form and Instruction
CMS-10431 Notice of Participation Screenshot PCHQR_NOP application March_12_2013.pdf Form and Instruction
CMS PCH Crosswalk.March_14_2013.pdf Crosswalk IC Document

Information Collection (IC) Details

View Information Collection (IC)

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:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10431	Oncology Care Measures Online Data Entry Tool	Data collection Feb_7_2013.Oncology Care Measures.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10431	Surgical Care Improvement Online Data Entry Tool	Data collection Feb_7_2013.SCIP.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10431	Surgical Care Improvement Paper Submission	Data Collection.Paperbased form.SCIP.Feb_08_2013.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10431	Oncology Care Paper Submission	Data collectionFeb_8_2013.Oncology Care Measures.Paper Form.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10431	Extroadinary Circumstances/Disaster Extension or Waiver Request Form	ExtraordinaryCircumstance Waiver.Application.Jan_16_2013.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10431	Extroadinary Circumstance Paper Form	ExtraordinaryCircumstance Waiver.Paper submission.Feb_8_2013.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10431	Measure Exception Form	Measure Waiver.Feb_8_2013.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10431	Notice of Participation Paper Form	NoP Paper Form.April_26_2013.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10431	Data Accuracy and Completeness Agreement	PCHQR.DACA form.Paper.Feb_8_2013.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10431	Data Accuracy and Completeness Agreement Screen Shot	PCHQR_DACA Application March_11_2013.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10431	Notice of Participation Screenshot	PCHQR_NOP application March_12_2013.pdf	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

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 %

	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	63,468	36,195	27,273
Annual IC Time Burden (Hours)	602,965	534,783	68,182
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Crosswalk	CMS PCH Crosswalk.March_14_2013.pdf	05/15/2013

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.