Information Collection

PQRS Data Validation Project Electronic Survey

IC 213102 under ICR 201602-0938-001 · OMB 0938-1255.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10519 Attachment D - Survey PQRS Data Validation Project Electronic Survey	Form and Instruction
CMS-10519 Attachment D - Survey PQRS Data Validation Electronic Survey - Att-D-Survey_OY1_20150126.docx	Form and Instruction
PQRS Data Validation Electronic Survey - Att-C-Recruitment_OY1_20150126.docx Attachment C - Survey Invitation	IC Document
PSV Information Paper - Awareness (Final 06052015).docx Primary Source Verification Paper	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

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 and Instruction	CMS-10519				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 115

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	115	115
Annual IC Time Burden (Hours)	173	173
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment C - Survey Invitation		02/09/2016
Primary Source Verification Paper		02/09/2016

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

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