Information Collection

Value Based Purchasing Arrangement Data

IC 242409 under ICR 202006-0938-015 · OMB 0938-1385.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1385 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10722 Value Based Purchasing Arrangement Data	Form
CMS-10722 Value Based Purchasing Arrangement Data Worksheet VBPstatedata worksheet.xlsx	Form

IC Title:

Value Based Purchasing Arrangement Data

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-10722	Value Based Purchasing Arrangement Data Worksheet	VBPstatedata worksheet.xlsx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 51

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
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	51	51
Annual IC Time Burden (Hours)	306	306
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.