Information Collection

?414.1360 (Improvement Activities Performance Category) Call for Activities

IC 227507 under ICR 201810-0938-007 · OMB 0938-1314.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1314 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10621 ?414.1360 (Improvement Activities Performance Category) Call for Activities	Form
CMS-10621 Improvement Activities Performance Category (Call for Ac Appendix I 2019 IA Call for Activities Submission Form.docx	Form

IC Title:

§414.1360 (Improvement Activities Performance Category) Call for Activities

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 414.1360

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	CMS-10621	Improvement Activities Performance Category (Call for Activities Submission Form)	Appendix I 2019 IA Call for Activities Submission Form.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 125

Number of Respondents for Small Entity: 125

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
	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	125	-25	150
Annual IC Time Burden (Hours)	250	175	75
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.