Information Collection

Kccq-12

IC 204894 under ICR 202011-0938-010 · OMB 0938-1202.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10443 KCCQ-10	Form and Instruction
Form CMS-10443 KCCQ Form KCCQ-12	Form and Instruction
CMS-10443 KCCQ Form Kansas City Cardiomyopathy Questionnaire for Patients (with numbering) (with PRA disclosure) 2020.pdf	Form and Instruction
CMS-10443 KCCQ Form Kansas City Cardiomyopathy Questionnaire for Patients (with numbering) (with PRA disclosure) 2020.pdf	Form and Instruction

IC Title:

KCCQ-12

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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 and Instruction	CMS-10443				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 37,221

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	111,663	67,050	44,613
Annual IC Time Burden (Hours)	13,027	7,673	5,354
Annual IC Cost Burden (Dollars)	0	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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