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⚠️ Notice: This information collection may be referencing outdated material.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

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

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	CMS-10805 and CMS-10806	Agency IC Tracking Number:	CSQ

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
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 %

	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

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.