Information Collection

NQIIC Nursing Home Survey

IC 248179 under ICR 202107-0938-001 · OMB 0938-1424.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
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

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:

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-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 %

table that charts list of burden
	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

table that charts IC Documents
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.