Information Collection

Part A Providers Web-Based Survey

IC 243671 under ICR 202009-0938-010 · OMB 0938-1348.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10633 Part A Providers Web-Based Survey	Form and Instruction
CMS-10633 Web Based Surveys QDEC-Attachment A-WebBasedSurvey_508compliant.pdf	Form and Instruction
CMS-10633 Part A Survey Screenshots QDEC_Attachment E Part A survey screenshots.pdf	Form
QDEC_Attachment A Web Based Survey_508 Compliant.pdf	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

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-10633	Web Based Surveys	QDEC-Attachment A-WebBasedSurvey_508compliant.pdf		Yes	Yes	Fillable Fileable
Form	CMS-10633	Part A Survey Screenshots	QDEC_Attachment E Part A survey screenshots.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,544

Number of Respondents for Small Entity: 1,524

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	2,544	2,544
Annual IC Time Burden (Hours)	425	425
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
	QDEC_Attachment A Web Based Survey_508 Compliant.pdf	06/27/2017

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