Data Management Plan Self-Attestation Questionnaire

Data Management Plan Self-Attestation Questionnaire (DMPSAQ) (CMS-10733)

Documents and Forms

Document Name Document Type
Form CMS-10733 Data Management Plan Self-Attestation Questionnaire Form and Instruction
CMS-10733 DMP SAQ CMS DPSP DMP SAQ 3.1_2020.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Data Management Plan Self-Attestation Questionnaire	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10733	DMP SAQ	CMS DPSP DMP SAQ 3.1_2020.pdf		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,000	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 %

	Requested	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	1,000	1,000
Annual IC Time Burden (Hours)	1,500	1,500
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.