LAN Summit – Total Event Evaluations (CMS-10713)

Generic Clearance for the Heath Care Payment Learning and Action Network (CMS-10575)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1297 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10713 LAN Summit – Total Event Evaluations (CMS-10713) Form and Instruction
CMS-10713 Guidebook - Breakout Session Evaluation Questions Guidebook - Breakout Session Evaluation Questions.pdf Form and Instruction
CMS-10713 Mentimeter - Overall Summit Evaluation Questions Mentimeter - Overall Summit Evaluation Questions.pdf Form and Instruction
CMS-10713 Overall Eval Overall Eval_V1.docx Form and Instruction
CMS-10713 Session Evaluation Session Eval.docx Form and Instruction
GenIC19 LAN Summit Evaluation Form Clean.docx Supporting Statement CMS-10713 IC Document

Information Collection (IC) Details

IC Title:	LAN Summit – Total Event Evaluations (CMS-10713)	Agency IC Tracking Number:	CMMI

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10713	Guidebook - Breakout Session Evaluation Questions	Guidebook - Breakout Session Evaluation Questions.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10713	Mentimeter - Overall Summit Evaluation Questions	Mentimeter - Overall Summit Evaluation Questions.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10713	Overall Eval	Overall Eval_V1.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10713	Session Evaluation	Session Eval.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 400	Number of Respondents for Small Entity: 0

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

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	400	400
Annual IC Time Burden (Hours)	34	34
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Supporting Statement CMS-10713	GenIC19 LAN Summit Evaluation Form Clean.docx	08/20/2019

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