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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
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

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:

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-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 %

table that charts list of burden
	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

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.