Information Collection

(CMS-10723) 12SOW Patient Activiation Assessment

IC 241125 under ICR 201904-0938-017 · OMB 0938-1185.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1185 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10723 Patient Activation Survey (CMS-10723) 12SOW Patient Activiation Assessment	Form and Instruction
CMS-10723 Patient Activation Survey Patient Activation Survey_ALLQINS_REV012021.pdf	Form and Instruction
CMS-10723 Patient Activation Survey_ALLQINS_04022020.pdf CMS-10723 Supporting Statement	IC Document

IC Title:

(CMS-10723) 12SOW Patient Activiation Assessment

Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10723				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 100,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

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	100,000	100,000
Annual IC Time Burden (Hours)	3,333	3,333
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
CMS-10723 Supporting Statement		04/03/2020

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

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