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

Evaluation of the CMS Quality Improvement Organizations: Medication Safety and Adverse Drug Event Prevention (CMS-10675)

Documents and Forms

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

Information Collection (IC) Details

IC Title:	Evaluation of the CMS Quality Improvement Organizations: Medication Safety and Adverse Drug Event Prevention	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection 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 %

	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

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.