Information Collection

Evaluation of the CMS Quality Improvement Organizations: Medication Safety and Adverse Drug Event Prevention

IC 234410 under ICR 201812-0938-002 · OMB 0938-1356.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10675 Evaluation of the CMS Quality Improvement Organizations: Medication Safety and Adverse Drug Event Prevention	Form and Instruction
CMS-10675 Appendix A.1 Medication Safety and Adverse Drug Event Pr CMS-10675_App_A.1_Survey_Instrument_Screenshots_11.14.2018_v2_508.docx	Form and Instruction
CMS-10675 Appendix A: Survey Instrument - Medication Safety and Ad CMS-10675_App_A_Survey Instrument_Revised_11-07-18_508.docx	Form and Instruction
CMS-10675_App_B_Communications_110118_508.docx Appendix B. Data Collection Pre-Notification Communicatio	IC Document
CMS-10675_Attachment_1_Crosswalk_of_Existing_and_New_ADE_Data_Elements_06-04-18_508.docx Crosswalk Between Evaluation Data Needs, Existing Data Sources, and Proposed Data Collection	IC Document
CMS-10675_Attachment_2_Results_from_Claims_Analysis_051818_508.docx Attachment 2 - claims analysis results	IC Document
CMS-10675_Attachment_3_Instrument_Revision_Crosswalk_11-13-2018_508.docx Attachment 3 - Crosswalk for Changes to Survey Instrument	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-10675	Appendix A.1 Medication Safety and Adverse Drug Event Prevention Survey Screenshots	CMS-10675_App_A.1_Survey_Instrument_Screenshots_11.14.2018_v2_508.docx		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10675	Appendix A: Survey Instrument - Medication Safety and Adverse Drug Event Prevention (A Web-based Survey)	CMS-10675_App_A_Survey Instrument_Revised_11-07-18_508.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,200

Number of Respondents for Small Entity: 357

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	1,200	1,200
Annual IC Time Burden (Hours)	300	300
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Appendix B. Data Collection Pre-Notification Communicatio	CMS-10675_App_B_Communications_110118_508.docx	12/04/2018
Crosswalk Between Evaluation Data Needs, Existing Data Sources, and Proposed Data Collection	CMS-10675_Attachment_1_Crosswalk_of_Existing_and_New_ADE_Data_Elements_06-04-18_508.docx	12/04/2018
Attachment 2 - claims analysis results	CMS-10675_Attachment_2_Results_from_Claims_Analysis_051818_508.docx	12/04/2018
Attachment 3 - Crosswalk for Changes to Survey Instrument	CMS-10675_Attachment_3_Instrument_Revision_Crosswalk_11-13-2018_508.docx	12/04/2018

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