Information Collection

PPS-exempt Cancer Hosptital Quality Reporitng (PCQR) Program

IC 202342 under ICR 202004-0938-007 · OMB 0938-1175.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1175 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10431 PPS-exempt Cancer Hosptital Quality Reporitng (PCQR) Program	Form and Instruction
CMS-10431 EBRT Pop Sample Application Form EBRT_webapplication_July_24_2014_03242017 (508).docx	Form and Instruction
CMS-10431 EBRT Paper based Form EBRT_PopSamp_paperbased_ July_22_2014_03242017 (508).docx	Form and Instruction
CMS-10431 Oncology Care Measures Pop Sample application Form OCMs PopSample_application_April 17 2014_03242017 (508).docx	Form and Instruction
CMS-10431 Measure Exception Form PCH Measure Exception Form_01022014_updated_03242017 (508).docx	Form and Instruction
CMS-10431 Oncology Cares Measures Paper Submission PQ 2019-01-29 V1 Data Collection - Oncology Care Measures Paper Form (PC....docx	Form and Instruction
CMS-10431 Data Accuracy and Completeness Form PQ V2 2020-05-05 DACA_Mockup_PCHQR.DOCX	Form and Instruction
CMS-10431 Notice of Participation PCH NOP Paper Form_03242017 (508).docx	Form and Instruction

IC Title:

PPS-exempt Cancer Hosptital Quality Reporitng (PCQR) Program

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

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 and Instruction	CMS-10431	EBRT Pop Sample Application	Form EBRT_webapplication_July_24_2014_03242017 (508).docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10431	EBRT Paper based	Form EBRT_PopSamp_paperbased_ July_22_2014_03242017 (508).docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10431	Oncology Care Measures Pop Sample application	Form OCMs PopSample_application_April 17 2014_03242017 (508).docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10431	Measure Exception Form	PCH Measure Exception Form_01022014_updated_03242017 (508).docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10431	Oncology Cares Measures Paper Submission	PQ 2019-01-29 V1 Data Collection - Oncology Care Measures Paper Form (PC....docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10431	Data Accuracy and Completeness Form	PQ V2 2020-05-05 DACA_Mockup_PCHQR.DOCX	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10431	Notice of Participation	PCH NOP Paper Form_03242017 (508).docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 11

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	Previously Approved
Annual Number of Responses for this IC	142,406	142,406
Annual IC Time Burden (Hours)	75,779	75,779
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.