Information Collection

Hospital Survey for Specified Covered Outpatient Drugs (SCODs)

IC 239876 under ICR 202008-0938-005 · OMB 0938-1374.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10709 Drug Survey Hospital Survey for Specified Covered Outpatient Drugs (SCODs)	Form
Form CMS-10709 Instruction Sheet for Collecting Acquisition Costs Hospital Survey for Specified Covered Outpatient Drugs (SCODs)	Form and Instruction
CMS-10709 Drug Survey SurveyWorksheet_CMS_ (4-23-20).xlsx	Form
CMS-10709 Instruction Sheet for Collecting Acquisition Costs CMS-10709.Survey Instruction Clean (4-23-20).docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

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-10709				Yes	Yes	Fillable Printable
Form and Instruction	CMS-10709				Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,408

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
	Approved	Previously Approved
Annual Number of Responses for this IC	1,408	1,408
Annual IC Time Burden (Hours)	67,584	67,584
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.

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