Information Collection

Reporting

IC 220190 under ICR 202101-0938-004 · OMB 0938-1309.

Documents and Forms

Document Name Document Type
Form CMS-10589 Reporting Form and Instruction
CMS-10589 QECP Annual Report Workbook QECP 2019 ARW_Final Version for CMS Review _1.27.20_508 compliant.xlsx Form and Instruction
CMS-10589 QECP Annual Report Workbook QECP 2019 ARW_Final Version.xlsx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Reporting	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 401.719(b)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10589	QECP Annual Report Workbook	QECP 2019 ARW_Final Version.xlsx		Yes	Yes	Fillable Fileable Signable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 15	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	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	15	15
Annual IC Time Burden (Hours)	750	750
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.