Information Collection

User Acceptance Testing for the Medicare Ground Ambulance Data Collection System (GADCS) (CMS-10754)

IC 257134 under ICR 202211-0938-011 · OMB 0938-1185.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10754 User Acceptance Testing for the Medicare Ground Ambulance Data Collection System (GADCS) (CMS-10754)	Form and Instruction
GADCS User Guide Clean.docx	Instruction
GADCS User Guide Clean.docx	Instruction
CMS-10754 GADCS Feedback Application GADCS Draft Feedback Clean.docx	Form and Instruction
CMS-10754 GADCS Feedback Application GADCS Draft Feedback Clean.docx	Form and Instruction
UAT Recruitment email.docx UAT Recruitment email	IC Document
UAT Recruitment email.docx UAT Recruitment email	IC Document
CMS-10754 - Fast Track Supporting Statement.docx CMS-10754 - Fast Track Supporting Statement	IC Document
CMS-10754 - Fast Track Supporting Statement.docx CMS-10754 - Fast Track Supporting Statement	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-10754	GADCS Feedback Application	GADCS Draft Feedback Clean.docx		Yes	Yes	Fillable Fileable
Instruction			GADCS User Guide Clean.docx		Yes	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 80

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: 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	80	80
Annual IC Time Burden (Hours)	160	160
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
UAT Recruitment email	UAT Recruitment email.docx	11/28/2022
CMS-10754 - Fast Track Supporting Statement	CMS-10754 - Fast Track Supporting Statement.docx	11/28/2022

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