Information Collection

Survey of Eligible Professionals and Administrators

IC 209944 under ICR 201401-0938-005 · OMB 0938-1226.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10482 Survey of Eligible Professionals and Administrators	Form and Instruction
CMS-10482 Attachment A - List of Eligible Professionals Attachment_A.pdf	Form and Instruction
CMS-10482 Attachment B - Eligible Professionals and Practice Admin Attachment_B.pdf	Form and Instruction
CMS-10482 Attachment B7 - Screen Shots Attachment B7_Screenshots_PQRS_Survey_Instr.pdf	Form and Instruction
CMS-10482 Attachment C - Interview Topic Guides and Correspondence Attachment_C.pdf	Form and Instruction
Attachment_B6_Fact_Sheet.pdf Attachment B6 - Fact Sheet	IC Document
Attachment F_PQRS_Revisions_to_CMS.pdf Attachment F - Crosswalk	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10482	Attachment A - List of Eligible Professionals	Attachment_A.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10482	Attachment B - Eligible Professionals and Practice Administrators Surveys and Correspondence (B1-B5)	Attachment_B.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10482	Attachment B7 - Screen Shots	Attachment B7_Screenshots_PQRS_Survey_Instr.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10482	Attachment C - Interview Topic Guides and Correspondence	Attachment_C.pdf	No	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 8,450

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: 60 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	8,450	8,450
Annual IC Time Burden (Hours)	1,705	1,705
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment B6 - Fact Sheet	Attachment_B6_Fact_Sheet.pdf	11/26/2013
Attachment F - Crosswalk	Attachment F_PQRS_Revisions_to_CMS.pdf	11/26/2013

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