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⚠️ Notice: This information collection may be referencing outdated material.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

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

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.