Electronic Visit Verification (EVV) Compliance Survey

Electronic Visit Verification (EVV) Compliance Survey (CMS-10680)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1360 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10680 Electronic Visit Verification (EVV) Compliance Survey Form
EVV-Compliance-Survey-Instructions.docx Instruction
CMS-10680 EVV Home Health Care Services (HHCS) Survey HCBS-EVV-HHCS-Survey-06052019.pptx Form
CMS-10680 EVV Personal Care Services (PCS) Survey HCBS-EVV-PCS-Survey-06052019.pptx Form

Information Collection (IC) Details

IC Title:	Electronic Visit Verification (EVV) Compliance Survey	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10680	EVV Personal Care Services (PCS) Survey	HCBS-EVV-PCS-Survey-06052019.pptx	Yes	Yes	Fillable Fileable
Form	CMS-10680	EVV Home Health Care Services (HHCS) Survey	HCBS-EVV-HHCS-Survey-06052019.pptx	Yes	Yes	Fillable Fileable
Instruction			EVV-Compliance-Survey-Instructions.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 56	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	336	336
Annual IC Time Burden (Hours)	504	504
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.