OMB.report

Federal forms, ICRs, and supporting documents

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
Document Name
Document Type
Form and Instruction
Form and Instruction
Form and Instruction
IC Document
IC Document
IC Document
IC Document
Information Collection (IC) Details

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Evaluation of the CMS Quality Improvement Organizations: Medication Safety and Adverse Drug Event Prevention
 
No New
 
Voluntary
 

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

Health Health Care Services

 

1,200 357
   
Private Sector Businesses or other for-profits
 
   100 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 1,200 0 1,200 0 0 0
Annual IC Time Burden (Hours) 300 0 300 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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.