Information Collection

HQIC Hospital Survey

IC 248181 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⚠️ Notice: This information collection may be referencing outdated material.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 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

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:

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	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 %

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
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.