Information Collection

Hospice QRP Program Evaluation

IC 211030 under ICR 201403-0938-018 · OMB 0938-1243.

Documents and Forms

Document Name Document Type
Form CMS-10504 Hospice QRP Program Evaluation Form and Instruction
CMS-10504 Structured Interview Questions - Hospice HospiceMonitoringQuestions.11.14.13..pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Hospice QRP Program Evaluation	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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-10504	Structured Interview Questions - Hospice	HospiceMonitoringQuestions.11.14.13..pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: Long Term Care Hospitals Quality Reporting Program (LTCH QRP)	FR Citation: 78 FR 8535

Number of Respondents: 30	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: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	30	30
Annual IC Time Burden (Hours)	71	71
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.