Information Collection

PPS-exempt Cancer Hosptital Quality Reporitng (PCQR) Program

IC 202342 under ICR 201401-0938-010 · OMB 0938-1175.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10431 PPS-exempt Cancer Hosptital Quality Reporitng (PCQR) Program	Form and Instruction
CMS-10431 Oncology Care Measures Paper Submission Data collection Oncology Care Measures Paper Form_Revised 4.17.2014.docx	Form and Instruction
CMS-10431 SCIP Measures Paper Submission Data Collection Paperbased form SCIP 4.17.2014.docx	Form and Instruction
CMS-10431 EBRT Pop Sample Application Form EBRT PopSample_application_July_22_2014.docx	Form and Instruction
CMS-10431 EBRT Paper based Form EBRT_paperbased_July_24_2014.docx	Form and Instruction
CMS-10431 EBRT Pop Sample paper based Form EBRT_PopSamp_paperbased_ July_22_2014.docx	Form and Instruction
CMS-10431 EBRT web application Form EBRT_webapplication_July_24_2014.docx	Form and Instruction
CMS-10431 Oncology Care Measures Pop Sample application Form OCMs PopSample_application_April 17 2014.docx	Form and Instruction
CMS-10431 OCM Pop Sample paper based Form OCMs_PopSamp_paperbased_ April 17 2014.docx	Form and Instruction
CMS-10431 SCIP Pop Sample paper based Form SCIP PopSamp_paperbased_April 17 2014.docx	Form and Instruction
CMS-10431 SCIP Pop Sample Application Form SCIP PopSample_application April 17 2014.docx	Form and Instruction
CMS-10431 Data Accuracy and Completeness Acknowledgement PCH DACA Form_041714.doc	Form and Instruction
CMS-10431 Measure Exception Form PCH Measure Exception Form_01022014_updated_04172014.doc	Form and Instruction
CMS-10431 Notice of Participation form PCH NOP Paper Form_041714.docx	Form and Instruction
PCHQR Burden Estimate_7 24 2014.docx burden estimate	IC Document
PCHQR PRA_Appendix A Aug_4_2014.V2.docx Appendix A	IC Document
PCHQR PRA_Appendix B.July_24_2014.docx Appendix B	IC Document
Sampling .docx Sampling e-mail	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:

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-10431	Oncology Care Measures Paper Submission	Data collection Oncology Care Measures Paper Form_Revised 4.17.2014.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10431	SCIP Measures Paper Submission	Data Collection Paperbased form SCIP 4.17.2014.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10431	EBRT Pop Sample Application	Form EBRT PopSample_application_July_22_2014.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10431	EBRT Paper based	Form EBRT_paperbased_July_24_2014.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10431	EBRT Pop Sample paper based	Form EBRT_PopSamp_paperbased_ July_22_2014.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10431	EBRT web application	Form EBRT_webapplication_July_24_2014.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10431	Oncology Care Measures Pop Sample application	Form OCMs PopSample_application_April 17 2014.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10431	OCM Pop Sample paper based	Form OCMs_PopSamp_paperbased_ April 17 2014.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10431	SCIP Pop Sample paper based	Form SCIP PopSamp_paperbased_April 17 2014.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10431	SCIP Pop Sample Application	Form SCIP PopSample_application April 17 2014.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10431	Data Accuracy and Completeness Acknowledgement	PCH DACA Form_041714.doc	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10431	Measure Exception Form	PCH Measure Exception Form_01022014_updated_04172014.doc	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10431	Notice of Participation form	PCH NOP Paper Form_041714.docx	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 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	413,556	386,283	27,273
Annual IC Time Burden (Hours)	206,891	138,709	68,182
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
burden estimate	PCHQR Burden Estimate_7 24 2014.docx	08/14/2014
Appendix A	PCHQR PRA_Appendix A Aug_4_2014.V2.docx	08/14/2014
Appendix B	PCHQR PRA_Appendix B.July_24_2014.docx	08/14/2014
Sampling e-mail	Sampling .docx	08/14/2014

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