Information Collection

Electronic Visit Verification (EVV) Compliance Survey

IC 235002 under ICR 201902-0938-010 · OMB 0938-1360.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.