12th SOW Patient Activation Assessment (CMS-10723)

Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery (CMS-10415)

Documents and Forms

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

Information Collection (IC) Details

IC Title:	12th SOW Patient Activation Assessment (CMS-10723)	Agency IC Tracking Number:

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-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 %

	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

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.