RCHD Evaluation Interview Protocols and Annual Progress Report Tool -- private hospitals

Evaluation of the Rural Community Hospital Demonstration

Documents and Forms

Document Name Document Type
Form CMS-10508 RCHD Evaluation Interview Protocols and Annual Progress Report Tool -- private hospitals Form and Instruction
CMS-10508 Data Collection Protocols RCHD_OMB_protocols_7Nov2013.docx Form and Instruction

Information Collection (IC) Details

IC Title:	RCHD Evaluation Interview Protocols and Annual Progress Report Tool -- private hospitals	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Mandatory

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-10508	Data Collection Protocols	RCHD_OMB_protocols_7Nov2013.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 15	Number of Respondents for Small Entity: 8

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 64 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	23	23
Annual IC Time Burden (Hours)	168	168
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.