IPRO Community of Care Coalitions Collaborator Survey (CMS-10771)

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

Documents and Forms

Document Name Document Type
Form CMS-10771 IPRO Community of Care Coalitions Collaborator Survey (CMS-10771) Form and Instruction
CMS-10771 IPRO Collaborator - Community of Care Coalitions Survey CMS-10771 2022 IPRO Collaborator - Community of Care Coalitions.pdf Form and Instruction
CMS-10771 IPRO Collaborator - Community of Care Coalitions Survey CMS-10771 2022 IPRO Collaborator - Community of Care Coalitions.pdf Form and Instruction
CMS-10771 Generic_Clearance_Submission_IPRO - Community of Care Coalitions V2.docx CMS-10771 Generic_Clearance_Submission_IPRO - Community of Care Coalitions V2 IC Document
CMS-10771 Generic_Clearance_Submission_IPRO - Community of Care Coalitions V2.docx CMS-10771 Generic_Clearance_Submission_IPRO - Community of Care Coalitions V2 IC Document

Information Collection (IC) Details

IC Title:	IPRO Community of Care Coalitions Collaborator Survey (CMS-10771)	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-10771	IPRO Collaborator - Community of Care Coalitions Survey	CMS-10771 2022 IPRO Collaborator - Community of Care Coalitions.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 50	Number of Respondents for Small Entity: 0

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

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	50	50
Annual IC Time Burden (Hours)	8	8
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
CMS-10771 Generic_Clearance_Submission_IPRO - Community of Care Coalitions V2	CMS-10771 Generic_Clearance_Submission_IPRO - Community of Care Coalitions V2.docx	11/28/2022

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