Information Collection

Quality Improvement Strategy Implementation Plan and Progress Report Form

IC 217708 under ICR 202012-0938-010 · OMB 0938-1286.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1286 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10540 Quality Improvement Strategy Implementation Plan and Progress Report Form	Form and Instruction
CMS-10540 QIS-Implementation-Plan CMS-10540 - PY2022_QIS-Implementation-Plan_f.pdf	Form and Instruction
CMS-10540 QIS-Implementation-Plan CMS-10540 - PY2022_QIS-Implementation-Plan_f.pdf	Form and Instruction
cms-10540 2022 Modification Summary Supplement CMS-10540 - PY2022 Modification Summary Supplement_f.pdf	Form and Instruction
cms-10540 2022 Modification Summary Supplement CMS-10540 - PY2022 Modification Summary Supplement_f.pdf	Form and Instruction
CMS-10540 2020 QIS Progress Report CMS-10540 - PY2022_QIS-Progress-Report.pdf	Form and Instruction
CMS-10540 2020 QIS Progress Report CMS-10540 - PY2022_QIS-Progress-Report.pdf	Form and Instruction

IC Title:

Quality Improvement Strategy Implementation Plan and Progress Report Form

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 45 CFR 156.200(b)(5) 45 CFR 156.1300 45 CFR 156.200(h)

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10540	QIS-Implementation-Plan	CMS-10540 - PY2022_QIS-Implementation-Plan_f.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	cms-10540	2022 Modification Summary Supplement	CMS-10540 - PY2022 Modification Summary Supplement_f.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10540	2020 QIS Progress Report	CMS-10540 - PY2022_QIS-Progress-Report.pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 250

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: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	250	0	250
Annual IC Time Burden (Hours)	11,000	-13,000	24,000
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.