Information Collection

Evaluation of the CMS Quality Improvement Organizations: Reducing Healthcare-Acquired Conditions in Nursing Homes

IC 224413 under ICR 201611-0938-007 · OMB 0938-1330.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10622 Evaluation of the CMS Quality Improvement Organizations: Reducing Healthcare-Acquired Conditions in Nursing Homes	Form and Instruction
CMS-10622 Nursing Home Survey Instrument CMS-10622_App_A1_Nursing_Home_Survey_Instrument_110416.docx	Form and Instruction
CMS-10622 Nursing Home Interview CMS-10622_App_A2_Nursing_Home_Interview_110416.docx	Form and Instruction
CMS-10622 Peer Coach Interview CMS-10622_App_A3_Peer_Coach_Interview_110416.docx	Form and Instruction
CMS-10622 QIN-QIO Focus Group Guide CMS-10622_App_A4_QIN-QIO_Focus_Group_Guide_110416.docx	Form and Instruction
CMS-10622 QIN-QIO Interview CMS-10622_App_A5_QIN-QIO_Interview_110416.docx	Form and Instruction
CMS-10622_Crosswalk_110416.docx Crosswalk	IC Document
CMS-10622_App_B_Communications_110416.docx Data Collection Pre-Notification Communications	IC Document
CMS-10622_Attachment 1. Crosswalk of Existing and New Nursing Home Data Elements.docx Attachment 1: Crosswalk of New and Existing Nursing Home Data Elements	IC Document

IC Title:

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-10622	Nursing Home Survey Instrument	CMS-10622_App_A1_Nursing_Home_Survey_Instrument_110416.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10622	Nursing Home Interview	CMS-10622_App_A2_Nursing_Home_Interview_110416.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10622	Peer Coach Interview	CMS-10622_App_A3_Peer_Coach_Interview_110416.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10622	QIN-QIO Focus Group Guide	CMS-10622_App_A4_QIN-QIO_Focus_Group_Guide_110416.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10622	QIN-QIO Interview	CMS-10622_App_A5_QIN-QIO_Interview_110416.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 856

Number of Respondents for Small Entity: 260

Affected Public: Private Sector

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

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	856	856
Annual IC Time Burden (Hours)	255	255
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Crosswalk	CMS-10622_Crosswalk_110416.docx	11/14/2016
Data Collection Pre-Notification Communications	CMS-10622_App_B_Communications_110416.docx	11/14/2016
Attachment 1: Crosswalk of New and Existing Nursing Home Data Elements	CMS-10622_Attachment 1. Crosswalk of Existing and New Nursing Home Data Elements.docx	05/24/2017

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