Information Collection

Qualified Registry or QCDR Vendors - Self Nomination

IC 201578 under ICR 201511-0938-008 · OMB 0938-1059.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10276 Qualified Registry or QCDR Vendors - Self Nomination	Form
CMS-10276 Self Nomination Screen Shot - Self-nomination Form.docx	Form

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 414.90 42 CFR 414.92

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10276	Self Nomination	Screen Shot - Self-nomination Form.docx		Yes	Yes	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: Performance Measurement and Reporting System

FR Citation: 72 FR 52133

Number of Respondents: 150

Number of Respondents for Small Entity: 50

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	150	150
Annual IC Time Burden (Hours)	1,500	1,500
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.