Information Collection

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

IC 257136 under ICR 202211-0938-011 · OMB 0938-1185.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10771 IPRO Community of Care Coalitions Collaborator Survey (CMS-10771)	Form and Instruction
Form CMS-10771 IPRO Collaborator - Community of Care Coalitions Survey 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

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-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 %

table that charts list of burden
	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

table that charts IC Documents
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.