Information Collection

CMS-10805 and CMS-10806

IC 252213 under ICR 202006-0938-020 · OMB 0938-1399.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1399 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10805 CMS-10805 and CMS-10806	Form and Instruction
CMS-10805 Submissions Experience Survey CMS-10805 QPP Submissions Experience Survey.docx	Form and Instruction
CMS-10806 Presubmissions experience survey CMS-10806 QPP Presubmissions experience survey.docx	Form and Instruction
CMS-10805 2021 QPP Submissions Experience Survey Supporting Statement 3-4-22.docx CMS-10805 Supporting Statement	IC Document
CMS-10806 2022 QPP Pre Submission Survey Supporting Statement 3-4-22.docx CMS-10806 Supporting Statement	IC Document
CMS-10805 and CMS-10806 Burden table.docx Burden Table	IC Document

IC Title:

CMS-10805 and CMS-10806

Agency IC Tracking Number:

CSQ

IC Status: New

Obligation to Respond: Voluntary

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 and Instruction	CMS-10805	Submissions Experience Survey	CMS-10805 QPP Submissions Experience Survey.docx		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10806	Presubmissions experience survey	CMS-10806 QPP Presubmissions experience survey.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 3,000

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	3,000	3,000
Annual IC Time Burden (Hours)	750	750
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
CMS-10805 Supporting Statement	CMS-10805 2021 QPP Submissions Experience Survey Supporting Statement 3-4-22.docx	03/16/2022
CMS-10806 Supporting Statement	CMS-10806 2022 QPP Pre Submission Survey Supporting Statement 3-4-22.docx	03/16/2022
Burden Table	CMS-10805 and CMS-10806 Burden table.docx	03/16/2022

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