Information Collection

QIC Demonstration Evaluation Contractor (QDEC): Web Based Surveys

IC 227305 under ICR 201706-0938-005 · OMB 0938-1348.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1348 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10633 QIC Demonstration Evaluation Contractor (QDEC): Web Based Surveys	Form and Instruction
CMS-10633 Web Based Surveys QDEC_Attachment A Web Based Survey_Revised for Passback.docx	Form and Instruction

IC Title:

QIC Demonstration Evaluation Contractor (QDEC): Web Based Surveys

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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10633	Web Based Surveys	QDEC_Attachment A Web Based Survey_Revised for Passback.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,540

Number of Respondents for Small Entity: 1,524

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
Annual Number of Responses for this IC	2,540	2,540
Annual IC Time Burden (Hours)	423	423
Annual IC Cost Burden (Dollars)	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.