Information Collection

KCCQ-10 Form

IC 215705 under ICR 201807-0938-003 · OMB 0938-1274.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1274 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10531 KCCQ-10 Form	Form and Instruction
CMS-10531 KCCQ-10 Kansas City Cardiomyopathy Questionnaire for Patients (with numbering) (2) (....pdf	Form and Instruction

IC Title:

KCCQ-10 Form

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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10531	KCCQ-10	Kansas City Cardiomyopathy Questionnaire for Patients (with numbering) (2) (....pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 3,897

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	11,691	10,491	1,200
Annual IC Time Burden (Hours)	1,364	-36	1,400
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.