Quality Reporting Process Survey (CMS-10562)

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⚠️ Notice: This information collection may be referencing outdated material.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-10562 Quality Reporting Process Survey (CMS-10562) Form and Instruction
CMS-10562 Quality Reporting Process Survey PSVA_1.0_Infromation_Sheet & Quality Reporting Process Survey.docx Form and Instruction
PSVA_1.0 Customer Results Clearance Submission Form.doc Quality Reporting Process Survey - Supporting Statement IC Document

Information Collection (IC) Details

IC Title:	Quality Reporting Process Survey (CMS-10562)	Agency IC Tracking Number:

IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10562	Quality Reporting Process Survey	PSVA_1.0_Infromation_Sheet & Quality Reporting Process Survey.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 50	Number of Respondents for Small Entity: 15

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Previously Approved
Annual Number of Responses for this IC	50	50
Annual IC Time Burden (Hours)	25	25
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Quality Reporting Process Survey - Supporting Statement	PSVA_1.0 Customer Results Clearance Submission Form.doc	05/21/2015

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