Information Collection

Nursing Home National Provider Survey

IC 217141 under ICR 201506-0938-009 · OMB 0938-1291.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10551 Nursing Home National Provider Survey	Form and Instruction
CMS-10551 Qualitative Interview Guide NH Attachment III NH Qualitative Interview Guide Mapping Research to Interview 2015 11 10.docx	Form and Instruction
CMS-10551 Structured Research Guide NH Attachment IV NH Structured Research Questions Mapped to Survey Questions 2015 11 10.docx	Form and Instruction
CMS-10551 Summary of Interview NH Attachment VI Summary of Interview Content 2015 11 10.docx	Form and Instruction
CMS-10551 List of Quality and Efficiency Measures NH Attachment VII List of Quality Measures 2015 11 10.docx	Form and Instruction
CMS-10551 Interview Topic Guide for Semi-Structured Interview NH Attachment VIII Interview Topic Guide for Semi-Structured Interview 2015 11 10.docx	Form and Instruction
CMS-10551 Standardized Hospital National Provider Survey NH Attachment XIII Standardized Nursing Home National Provider Survey 2015 10.docx	Form and Instruction
Nursing Home National Provider Survey List of Attachments 2015 11 10.docx Llst of Attachments	IC Document
NH Attachment XII Second Survey Cover Letter 2015 11 10.docx Second Survey Cover Letter	IC Document
NH Attachment XI Reminder Letter 2015 11 10.docx Attachment XI - Reminder Letter	IC Document
NH Attachment X First Mail Survey Cover Letter 2015 11 10.docx Attachment X - First Mail Survey Letter	IC Document
NH Attachment V Recruitment email or letter 2015 11 10.docx Recruitment Email	IC Document
NH Attachment IX Web Survey Invitation Email 2015 11 10.docx Attachment IX - Web Survey Invitation Emial	IC Document
NH Attachment I Development of Two National Provider Surverys 2015 11 10.docx Attachment I - Development of Two National Provider Surveys	IC Document
NH Attachment II Data Sources Used for 2015 Impact Assessment Report 2015 11 10.docx Attachment II - Data Sources used for 2015 Impact Assessment	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Nursing Home National Provider 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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10551	Qualitative Interview Guide	NH Attachment III NH Qualitative Interview Guide Mapping Research to Interview 2015 11 10.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10551	Structured Research Guide	NH Attachment IV NH Structured Research Questions Mapped to Survey Questions 2015 11 10.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10551	Summary of Interview	NH Attachment VI Summary of Interview Content 2015 11 10.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10551	List of Quality and Efficiency Measures	NH Attachment VII List of Quality Measures 2015 11 10.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10551	Interview Topic Guide for Semi-Structured Interview	NH Attachment VIII Interview Topic Guide for Semi-Structured Interview 2015 11 10.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10551	Standardized Hospital National Provider Survey	NH Attachment XIII Standardized Nursing Home National Provider Survey 2015 10.docx	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 940

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: 30 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	940	940
Annual IC Time Burden (Hours)	639	639
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Llst of Attachments	Nursing Home National Provider Survey List of Attachments 2015 11 10.docx	11/16/2015
Second Survey Cover Letter	NH Attachment XII Second Survey Cover Letter 2015 11 10.docx	11/16/2015
Attachment XI - Reminder Letter	NH Attachment XI Reminder Letter 2015 11 10.docx	11/16/2015
Attachment X - First Mail Survey Letter	NH Attachment X First Mail Survey Cover Letter 2015 11 10.docx	11/16/2015
Recruitment Email	NH Attachment V Recruitment email or letter 2015 11 10.docx	11/16/2015
Attachment IX - Web Survey Invitation Emial	NH Attachment IX Web Survey Invitation Email 2015 11 10.docx	11/16/2015
Attachment I - Development of Two National Provider Surveys	NH Attachment I Development of Two National Provider Surverys 2015 11 10.docx	11/16/2015
Attachment II - Data Sources used for 2015 Impact Assessment	NH Attachment II Data Sources Used for 2015 Impact Assessment Report 2015 11 10.docx	11/16/2015

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