Information Collection

GenIC#2 - 2015 Online Provider Assessment Survey

IC 217697 under ICR 201307-0938-017 · OMB 0938-1247.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1247 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10437: GenIC#2 GenIC#2 - 2015 Online Provider Assessment Survey	Form and Instruction
CMS-10437: GenIC#2 2015 Online Provider Assessment Survey CMS-10437 GenIC#2 Instrument -2015 Online Provider Survey.docx	Form and Instruction
CMS-10437 GenIC #2 - Incentive Justification.docx GneIC #2 - Incentive Justification	IC Document
CMS-10437 GenIC#2 - Supp. State. 2015 Online Provider Survey.docx CMS-10437 GenIC#2 - Supp. State. 2015 Online Provider Survey	IC Document

IC Title:

GenIC#2 - 2015 Online Provider Assessment Survey

Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10437: GenIC#2	2015 Online Provider Assessment Survey	CMS-10437 GenIC#2 Instrument -2015 Online Provider Survey.docx		Yes	Yes	Fillable Fileable Signable

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: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,200	1,200
Annual IC Time Burden (Hours)	360	360
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
GneIC #2 - Incentive Justification	CMS-10437 GenIC #2 - Incentive Justification.docx	07/29/2015
CMS-10437 GenIC#2 - Supp. State. 2015 Online Provider Survey	CMS-10437 GenIC#2 - Supp. State. 2015 Online Provider Survey.docx	07/29/2015

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