Information Collection

Compliance Review

IC 239115 under ICR 201912-0938-024 · OMB 0938-1390.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1390 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10662 Compliance Review	Form and Instruction
CMS-10662 ASETT_Assessment_All_Operating_Rule_Response_Attestation CMS-10662_ASETT_Assessment_All_Operating_Rule_Response_Attestation_v_1.2_Final_508.pdf	Form and Instruction
CMS-10662 ASETT_Assessment_Combined_Assessment_Package_Docs_v_1.2_ CMS-10662_ASETT_Assessment_Combined_Assessment_Package_Docs_v_1.2_Final_508.pdf	Form and Instruction
CMS-10662_ASETT_Assessment_Follow_Up_Request_For_Information_Letter_v_1.1_Final_508.pdf ASETT_Assessment_Follow_Up_Request_For_Information_Letter_v_1.1_Final_508.pdf	IC Document
CMS-10662_ASETT_Assessment_Final_Assessment_Report_v_1.1_Final_508.pdf ASETT_Assessment_Final_Assessment_Report_v_1.1_Final_508	IC Document
CMS-10662_ASETT_Assessment_Draft_Findings_Report_v_1.1_Final_508.pdf ASETT_Assessment_Draft_Findings_Report_v_1.1_Final_508	IC Document

IC Title:

Compliance Review

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Mandatory

CFR Citation: 45 CFR 160.310 45 CFR 160.308

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-10662	ASETT_Assessment_Combined_Assessment_Package_Docs_v_1.2_Final_508	CMS-10662_ASETT_Assessment_Combined_Assessment_Package_Docs_v_1.2_Final_508.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10662	ASETT_Assessment_All_Operating_Rule_Response_Attestation_v_1.2_Final_508	CMS-10662_ASETT_Assessment_All_Operating_Rule_Response_Attestation_v_1.2_Final_508.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 10

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 %

table that charts list of burden
	Requested	Program Change Due to New Statute
Annual Number of Responses for this IC	10	10
Annual IC Time Burden (Hours)	100	100
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
ASETT_Assessment_Follow_Up_Request_For_Information_Letter_v_1.1_Final_508.pdf	CMS-10662_ASETT_Assessment_Follow_Up_Request_For_Information_Letter_v_1.1_Final_508.pdf	12/30/2019
ASETT_Assessment_Final_Assessment_Report_v_1.1_Final_508	CMS-10662_ASETT_Assessment_Final_Assessment_Report_v_1.1_Final_508.pdf	12/30/2019
ASETT_Assessment_Draft_Findings_Report_v_1.1_Final_508	CMS-10662_ASETT_Assessment_Draft_Findings_Report_v_1.1_Final_508.pdf	12/30/2019

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