Information Collection

?495.24(e) Objectives/Measures (hospitals/CAHs)

IC 216082 under ICR 202112-0938-013 · OMB 0938-1278.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1278 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10552 ?495.24(e) Objectives/Measures (hospitals/CAHs)	Form and Instruction
QualityNet User Guide__(09-28-2021)_CLEAN.pdf	Instruction
QualityNet User Guide__(09-28-2021)_CLEAN.pdf	Instruction
CMS-10552 Attestation screen shots NG Attestation screen_(09-28-2021)_508_.pdf	Form and Instruction
CMS-10552 Attestation screen shots NG Attestation screen_(09-28-2021)_508_.pdf	Form and Instruction

IC Title:

§495.24(e) Objectives/Measures (hospitals/CAHs)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 495.24

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-10552	Attestation screen shots	NG Attestation screen_(09-28-2021)_508_.pdf		Yes	Yes	Fillable Fileable
Instruction			QualityNet User Guide__(09-28-2021)_CLEAN.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 3,300

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	3,300	3,300
Annual IC Time Burden (Hours)	21,450	21,450
Annual IC Cost Burden (Dollars)	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.