Information Collection

Evaluation of the Partnership for Patients

IC 230649 under ICR 201802-0938-011 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10656 Evaluation of the Partnership for Patients	Form and Instruction
CMS-10656 Hospital Survey on Prevention of Adverse Events and Redu 2_PEC Hospital Survey 12-14-17_clean.docx	Form and Instruction
CMS-10656 HIIN and PfP Support Contractor Interview Discussion Gui 3_HIIN and PfP Support Contractor Interviews Discussion Guide.pdf	Form and Instruction
PEC Hospital Survey_crosswalk.docx.doc Crosswalk - PEC hospitial survey	IC Document
4_National Hospital Survey Facility Advance letter Invitation and Remind....pdf Advance Letter Invitation and Reminders	IC Document
5_Email to HIINs Requesting Participation in Interviews.pdf Email to HIIN requesting participation	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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10656	Hospital Survey on Prevention of Adverse Events and Reduction of Readmissions	2_PEC Hospital Survey 12-14-17_clean.docx		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10656	HIIN and PfP Support Contractor Interview Discussion Guid	3_HIIN and PfP Support Contractor Interviews Discussion Guide.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 819

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

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

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	838	838
Annual IC Time Burden (Hours)	380	380
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Crosswalk - PEC hospitial survey	PEC Hospital Survey_crosswalk.docx.doc	03/09/2018
Advance Letter Invitation and Reminders	4_National Hospital Survey Facility Advance letter Invitation and Remind....pdf	03/12/2018
Email to HIIN requesting participation	5_Email to HIINs Requesting Participation in Interviews.pdf	03/12/2018

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