Information Collection

Hospital Survey for Specified Covered Outpatient Drugs (SCODs)

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

Documents and Forms

Document Name Document Type
Form CMS-10709 Hospital Survey for Specified Covered Outpatient Drugs (SCODs) Form
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

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Hospital Survey for Specified Covered Outpatient Drugs (SCODs)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10709	Drug Survey	SurveyWorksheet_CMS_ (4-23-20).xlsx		Yes	Yes	Fillable Printable
Form and Instruction	CMS-10709	Instruction Sheet for Collecting Acquisition Costs	CMS-10709.Survey Instruction Clean (4-23-20).docx		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 %

	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

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.