Information Collection

Ambulatory Surgical Center Quality Reporting (ASCQR) Program

IC 214868 under ICR 201607-0938-013 · OMB 0938-1270.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1270 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10530 Ambulatory Surgical Center Quality Reporting (ASCQR) Program	Form and Instruction
CMS-10530 Extroadinary Circumstance Online Form Extraordinary Circumstance Online Form_update_07152014_CLB_v10212014.docx	Form and Instruction
CMS-10530 Reconsideration Request Online Form ReconsiderationRequest Online Form_update_07152014_CLB_10222014.docx	Form and Instruction

IC Title:

Ambulatory Surgical Center Quality Reporting (ASCQR) Program

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

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-10530	Extroadinary Circumstance Online Form	Extraordinary Circumstance Online Form_update_07152014_CLB_v10212014.docx		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10530	Reconsideration Request Online Form	ReconsiderationRequest Online Form_update_07152014_CLB_10222014.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 5,260

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 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	1,407,576	662,760	744,816
Annual IC Time Burden (Hours)	367,711	-77,079	444,790
Annual IC Cost Burden (Dollars)	0	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.