Information Collection

12th SOW Patient Activation Assessment (CMS-10723)

IC 257110 under ICR 202211-0938-011 · OMB 0938-1185.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10723 12th SOW Patient Activation Assessment (CMS-10723)	Form and Instruction
CMS-10723 CMS-10723.Patient Activation Assessment CMS-10723.Patient Activation Assessment.docx	Form and Instruction
CMS-10723 CMS-10723.Patient Activation Assessment CMS-10723.Patient Activation Assessment.docx	Form and Instruction
CMS-10723.Patient Activation Survey Generic Submission Request.docx CMS-10723.Patient Activation Survey Generic Submission Request	IC Document
CMS-10723.Patient Activation Survey Generic Submission Request.docx CMS-10723.Patient Activation Survey Generic Submission Request	IC Document

IC Title:

Agency IC Tracking Number:

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-10723	CMS-10723.Patient Activation Assessment	CMS-10723.Patient Activation Assessment.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 100,000

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
Annual Number of Responses for this IC	100,000	100,000
Annual IC Time Burden (Hours)	3,333	3,333
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
CMS-10723.Patient Activation Survey Generic Submission Request	CMS-10723.Patient Activation Survey Generic Submission Request.docx	11/25/2022

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