Information Collection

Medicare Quality of Care Complaint Form

IC 191138 under ICR 201307-0938-023 · OMB 0938-1102.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1102 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10287 Medicare Quality of Care Complaint Form Form and Instruction
CMS-10287 Crosswalk Crosswalk CMS 0938 1102.pdf Form and Instruction
CMS-10287 Medicare Quality of Care Complaint Form Complaint Form.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Medicare Quality of Care Complaint Form	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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10287	Crosswalk	Crosswalk CMS 0938 1102.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10287	Medicare Quality of Care Complaint Form	Complaint Form.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 3,500	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	3,500	3,500
Annual IC Time Burden (Hours)	583	583
Annual IC Cost Burden (Dollars)	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.