Information Collection

Small Health Care Provider Quality Improvement Program Performance Improvement and Measurement System

IC 211726 under ICR 201810-0915-001 · OMB 0915-0387.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0387 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Small Health Care Provider Quality Improvement Program Performance Improvement and Measurement System	Form and Instruction
1 INSTRUMENT - 2017-2018 Quality Program Proposed PIMS Mea INSTRUMENT - 2017-2018 Quality Program Proposed PIMS Measures FINAL DRAFT.docx	Form and Instruction
RevisionsSmall Health Care Provider Quality Improvement Program Measures - 0915-0....docx Revisions	IC Document
0915-0387 Quality OMB Number and Expiration.jpg 0915-0387 Quality OMB Number and Expiration	IC Document
0915-0387 Quality Burden Statement.jpg 0915-0387 Quality Burden Statement	IC Document

IC Title:

Small Health Care Provider Quality Improvement Program Performance Improvement and Measurement System

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	1	INSTRUMENT - 2017-2018 Quality Program Proposed PIMS Measures FINAL DRAFT.docx	INSTRUMENT - 2017-2018 Quality Program Proposed PIMS Measures FINAL DRAFT.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 32

Number of Respondents for Small Entity: 32

Affected Public: Private Sector

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

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	32	32
Annual IC Time Burden (Hours)	704	704
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Revisions	RevisionsSmall Health Care Provider Quality Improvement Program Measures - 0915-0....docx	05/07/2018
0915-0387 Quality OMB Number and Expiration	0915-0387 Quality OMB Number and Expiration.jpg	10/24/2018
0915-0387 Quality Burden Statement	0915-0387 Quality Burden Statement.jpg	10/24/2018

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