Information Collection

Level I Monitoring Data Entry

IC 213217 under ICR 201612-0938-008 · OMB 0938-1264.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1264 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10525 Level I Monitoring Data Entry Form and Instruction
PRA CMS -10525 Addtional Information Part 1 Quality Reporting_23-05-2016_15-59-03.pdf Instruction
PRA CMS -10525 Additional Information Part 2 Quality Reporting_23-05-2016_15-58-07.pdf Instruction
PRA CMS -10525 Additional Information Part 3 Quality Reporting_23-05-2016_16-02-49.pdf Instruction
PACE Level I Guidance 2016.pdf Instruction
CMS-10525 PACE Quality Data Entry (Screen Shots) PACE Quality Data Entry HPMS PRA Screen Shots.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Level I Monitoring Data Entry	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:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10525	PACE Quality Data Entry (Screen Shots)	PACE Quality Data Entry HPMS PRA Screen Shots.docx	Yes	Yes	Fillable Fileable
Instruction			PRA CMS -10525 Addtional Information Part 1 Quality Reporting_23-05-2016_15-59-03.pdf	No		Printable Only
Instruction			PRA CMS -10525 Additional Information Part 2 Quality Reporting_23-05-2016_15-58-07.pdf	No		Printable Only
Instruction			PRA CMS -10525 Additional Information Part 3 Quality Reporting_23-05-2016_16-02-49.pdf	No		Printable Only
Instruction			PACE Level I Guidance 2016.pdf	No		Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 120	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	480	-23,520	24,000
Annual IC Time Burden (Hours)	153,600	147,600	6,000
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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.