Information Collection

Pilot Measure Questions

IC 240707 under ICR 202003-0938-007 · OMB 0938-1392.

Documents and Forms

Document Name Document Type
CMS-10714 - EMDI Pre-Post Pilot Measure-Questions.pdf Other-Pilot Measure Questions

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Pilot Measure Questions	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Pilot Measure Questions			CMS-10714 - EMDI Pre-Post Pilot Measure-Questions.pdf		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 240	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 %

	Requested	Program Change Due to New Statute
Annual Number of Responses for this IC	240	240
Annual IC Time Burden (Hours)	120	120
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.