Information Collection

IPRO Collaborator Satisfaction Survey-Request for Approval-Nursing Homes (CMS-10776)

IC 257125 under ICR 202211-0938-011 · OMB 0938-1185.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10776 IPRO Collaborator Satisfaction Survey-Request for Approval-Nursing Homes (CMS-10776)	Form and Instruction
CMS-10776 Collaborator Survey Nursing Home CMS-10776 Draft_2021 Collaborator Survey_Nursing Home_03.22.21 (1).pdf	Form and Instruction
CMS-10776 Collaborator Survey Nursing Home CMS-10776 Draft_2021 Collaborator Survey_Nursing Home_03.22.21 (1).pdf	Form and Instruction
CMS-10776 Generic_Clearance_Submission_IPRO - Nursing Home.docx CMS-10776 Generic_Clearance_Submission_IPRO - Nursing Home	IC Document
CMS-10776 Generic_Clearance_Submission_IPRO - Nursing Home.docx CMS-10776 Generic_Clearance_Submission_IPRO - Nursing Home	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-10776	Collaborator Survey Nursing Home	CMS-10776 Draft_2021 Collaborator Survey_Nursing Home_03.22.21 (1).pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 964

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
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	964	964
Annual IC Time Burden (Hours)	161	161
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
CMS-10776 Generic_Clearance_Submission_IPRO - Nursing Home	CMS-10776 Generic_Clearance_Submission_IPRO - Nursing Home.docx	11/25/2022

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