Development, Adaptation, Implementation, and Maintenance of Quality Measures for the Programs of All-Inclusive Care for the Elderly (PACE) (CMS-10557)

Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1185 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10557 Development, Adaptation, Implementation, and Maintenance of Quality Measures for the Programs of All-Inclusive Care for the Elderly (PACE) (CMS-10557) Form
PACE_Recruit_Reminder_Letter.pdf Other-Recruitment Reminder Letter
PACE_Recruitment_Letter.pdf Other-Recruitment Letter
CMS-10557 PACE Pilot Test Evaluation PACE Pilot Test Evaluation Survey.pdf Form
Generic Clearance Submission_PACE Quality Measures_v6 [rev 03-18-2015 by OSORA PRA].doc Supporting Statement IC Document

Information Collection (IC) Details

IC Title:	Development, Adaptation, Implementation, and Maintenance of Quality Measures for the Programs of All-Inclusive Care for the Elderly (PACE) (CMS-10557)	Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10557	PACE Pilot Test Evaluation	PACE Pilot Test Evaluation Survey.pdf	Yes	Yes	Fillable Printable
Other-Recruitment Reminder Letter			PACE_Recruit_Reminder_Letter.pdf	No		Paper Only
Other-Recruitment Letter			PACE_Recruitment_Letter.pdf	No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 180	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: 50 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	46	46
Annual IC Time Burden (Hours)	4,035	4,035
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Supporting Statement	Generic Clearance Submission_PACE Quality Measures_v6 [rev 03-18-2015 by OSORA PRA].doc	03/18/2015

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