NQIIC Nursing Home Survey

Evaluation of the CMS Network of Quality Improvement and Innovation Contractors Program (NQIIC) (CMS-10769)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1424 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10769 NQIIC Nursing Home Survey Form and Instruction
CMS-10769 NQIIC Nursing Home Survey CMS-10769_App_A_NQIIC_Nursing_Home_Survey_Instrument v2_508.pdf Form and Instruction
CMS-10769_App_C.1_Survey_Pre-Notification_NH_Communication.docx Survey Pre-notification Letter IC Document
CMS-10769_App_C.2_Nursing_Home_follow-up_VM_and_email_1_8_21.docx Nursing Home Follow-up Email IC Document
CMS-10769_Crosswalk_NursingHome_Survey_Questions_(QIN-QIO)_v2_508.pdf Crosswalk of Nursing Home Survey IC Document

Information Collection (IC) Details

IC Title:	NQIIC Nursing Home Survey	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-10769	NQIIC Nursing Home Survey	CMS-10769_App_A_NQIIC_Nursing_Home_Survey_Instrument v2_508.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 500	Number of Respondents for Small Entity: 250

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	500	500
Annual IC Time Burden (Hours)	165	165
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Survey Pre-notification Letter	CMS-10769_App_C.1_Survey_Pre-Notification_NH_Communication.docx	07/02/2021
Nursing Home Follow-up Email	CMS-10769_App_C.2_Nursing_Home_follow-up_VM_and_email_1_8_21.docx	07/02/2021
Crosswalk of Nursing Home Survey	CMS-10769_Crosswalk_NursingHome_Survey_Questions_(QIN-QIO)_v2_508.pdf	07/02/2021

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.