Information Collection

Hospital Survey for Specified Covered Outpatient Drugs (SCODs)

IC 239876 under ICR 202002-0938-001 · OMB 0938-1374.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1374 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10709 Hospital Survey for Specified Covered Outpatient Drugs (SCODs)	Form
CMS-10709 Drug Survey SurveyWorksheet_CMS_ (4-23-20).xlsx	Form
CMS-10709 Instruction Sheet for Collecting Acquisition Costs CMS-10709.Survey Instruction Clean (4-23-20).docx	Form and Instruction

IC Title:

Hospital Survey for Specified Covered Outpatient Drugs (SCODs)

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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10709	Drug Survey	SurveyWorksheet_CMS_ (4-23-20).xlsx		Yes	Yes	Fillable Printable
Form and Instruction	CMS-10709	Instruction Sheet for Collecting Acquisition Costs	CMS-10709.Survey Instruction Clean (4-23-20).docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,408

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 New Statute
Annual Number of Responses for this IC	1,408	1,408
Annual IC Time Burden (Hours)	67,584	67,584
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.