Information Collection

(CMS-10804) QPP Site Intercept Survey

IC 251182 under ICR 202009-0938-002 · OMB 0938-1397.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1397 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10804 (CMS-10804) QPP Site Intercept Survey	Form and Instruction
CMS-10804 QPP Intercept Survey CMS-10804 QPP Site Intercept Survey RFA - 508 Compliant.docx	Form and Instruction
CMS-10804 QPP Site Intercept Survey RFA - 508 Compliant.docx Supporting Statement	IC Document

IC Title:

(CMS-10804) QPP Site Intercept Survey

Agency IC Tracking Number:

CCSQ

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-10804	QPP Intercept Survey	CMS-10804 QPP Site Intercept Survey RFA - 508 Compliant.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,200

Number of Respondents for Small Entity: 0

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
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,200	1,200
Annual IC Time Burden (Hours)	100	100
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Supporting Statement	CMS-10804 QPP Site Intercept Survey RFA - 508 Compliant.docx	01/18/2022

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