Information Collection

Application and Re-application processes

IC 198017 under ICR 201504-0938-013 · OMB 0938-1144.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1144 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10394 Application and Re-application processes	Form and Instruction
QECP_Letter_of_Commitment.pdf	Instruction
CMS-10394 Application QECP_PaperBased_ApplicationForm.pdf	Form and Instruction
CMS-10294 QECP MEasure Production QA Worksheet QECP_MeasureProduction_QA_Worksheet.pdf	Form and Instruction
CMS-10394 QECP Measure Information Workbook QECP_Measure_Information_Workbook.pdf	Form and Instruction
CMS-10394 QECP Data Source Attestation QECP_DataSource_Attestation.pdf	Form and Instruction
CMS-10392 QECP Data Security Workbook QECP_DataSecurity_Workbook.pdf	Form and Instruction

IC Title:

Application and Re-application processes

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 401.703a

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-10394	Application	QECP_PaperBased_ApplicationForm.pdf	Yes	Yes	Fillable Fileable Signable
Form and Instruction	CMS-10294	QECP MEasure Production QA Worksheet	QECP_MeasureProduction_QA_Worksheet.pdf	Yes	Yes	Fillable Fileable Signable
Form and Instruction	CMS-10394	QECP Measure Information Workbook	QECP_Measure_Information_Workbook.pdf	Yes	Yes	Fillable Fileable Signable
Instruction			QECP_Letter_of_Commitment.pdf	Yes	Yes	Fillable Printable
Form and Instruction	CMS-10394	QECP Data Source Attestation	QECP_DataSource_Attestation.pdf	Yes	Yes	Fillable Fileable Signable
Form and Instruction	CMS-10392	QECP Data Security Workbook	QECP_DataSecurity_Workbook.pdf	Yes	Yes	Fillable Fileable Signable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 35

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	Previously Approved
Annual Number of Responses for this IC	35	35
Annual IC Time Burden (Hours)	6,833	6,833
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.