HQIC Hospital 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⚠️ Notice: This information collection may be referencing outdated material.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 HQIC Hospital Survey Form and Instruction
CMS-10769 HQIIC Hospital Survey CMS-10769_App_B_HQIC_Hospital_Survey_Instrument_v2_508.pdf Form and Instruction
CMS-10769_Crosswalk_Hospital_Survey_Questions_(HQIC)_v2_508.pdf Crosswalk - Hospital Survey IC Document
CMS-10769_App_C.3_Survey_Pre-Notification_Hosp_Communication.docx Pre-noitification letter for Hospital Survey IC Document
CMS-10769_App_C.4_Hospital_follow-up_VM_and_email_1_8_21.docx Hospital Follow-up email IC Document

Information Collection (IC) Details

IC Title:	HQIC Hospital 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	HQIIC Hospital Survey	CMS-10769_App_B_HQIC_Hospital_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: 275

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
Crosswalk - Hospital Survey	CMS-10769_Crosswalk_Hospital_Survey_Questions_(HQIC)_v2_508.pdf	07/02/2021
Pre-noitification letter for Hospital Survey	CMS-10769_App_C.3_Survey_Pre-Notification_Hosp_Communication.docx	07/06/2021
Hospital Follow-up email	CMS-10769_App_C.4_Hospital_follow-up_VM_and_email_1_8_21.docx	07/02/2021

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