Information Collection

(Improvement Activities Performance Category) Nomination of Improvement Activities (see SS-A Table 20)

IC 227507 under ICR 202007-0938-007 · OMB 0938-1314.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1314 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10621 (Improvement Activities Performance Category) Nomination of Improvement Activities (see SS-A Table 20)	Form
CMS-10621 Improvement Activities Performance Category: Call for Ac Appendix J 2020 IA Call for Activities Submission Form.pdf	Form

IC Title:

(Improvement Activities Performance Category) Nomination of Improvement Activities (see SS-A Table 20)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 414.1360

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-10621	Improvement Activities Performance Category: Call for Activities Submission Form	Appendix J 2020 IA Call for Activities Submission Form.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: Quality Payment Program (QPP), System No. 09â70â 0539

FR Citation: 83 FR 6587

Number of Respondents: 31

Number of Respondents for Small Entity: 31

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	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	31	0	31
Annual IC Time Burden (Hours)	93	31	62
Annual IC Cost Burden (Dollars)	0	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.