Information Collection

PQRS Data Validation Project Electronic Survey

IC 213102 under ICR 201409-0938-008 · OMB 0938-1255.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1255 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10519 PQRS Data Validation Project Electronic Survey	Form and Instruction
CMS-10519 PQRS Data Validation Electronic Survey PQRS Data Validation Electronic Survey - Att-D-Survey_v1.1.docx	Form and Instruction
PQRS Data Validation Electronic Survey - Att-C-Recruitment_v1.1.docx Recruitment documents	IC Document

IC Title:

PQRS Data Validation Project Electronic Survey

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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10519	PQRS Data Validation Electronic Survey	PQRS Data Validation Electronic Survey - Att-D-Survey_v1.1.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 115

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	115	115
Annual IC Time Burden (Hours)	173	173
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Recruitment documents	PQRS Data Validation Electronic Survey - Att-C-Recruitment_v1.1.docx	09/12/2014

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