Information Collection

Reporting

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

Documents and Forms

Documents and forms in this information collection
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

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:

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-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 %

table that charts list of burden
	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

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.