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

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

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Evaluation of the CMS Quality Improvement Organizations: Reducing Healthcare-Acquired Conditions in Nursing Homes	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection 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 %

	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

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.