Information Collection

KCCQ-10 Form

IC 215705 under ICR 202109-0938-014 · OMB 0938-1274.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10531 KCCQ-10 Form	Form and Instruction
CMS-10531 KCCQ-10 Kansas City Cardiomyopathy Questionnaire for Patients (with numbering) (with PRA disclosure) 2021.pdf	Form and Instruction

IC Title:

KCCQ-10 Form

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

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-10531	KCCQ-10	Kansas City Cardiomyopathy Questionnaire for Patients (with numbering) (with PRA disclosure) 2021.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 8,649

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	25,947	14,256	11,691
Annual IC Time Burden (Hours)	3,027	1,663	1,364
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
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.