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⚠️ Notice: This information collection may be referencing outdated material.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

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

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.