Information Collection

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

IC 257137 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 (1).docx	Instruction
GADCS User Guide (1).docx	Instruction
CMS-10754 GADCS Feedback Application GADCS Draft Feedback v2.docx	Form and Instruction
CMS-10754 GADCS Feedback Application GADCS Draft Feedback v2.docx	Form and Instruction
CMS-10754 Observed Testing Protocol Instrument Testing_Interview Protocol_.docx	Form and Instruction
CMS-10754 Observed Testing Protocol Instrument Testing_Interview Protocol_.docx	Form and Instruction
CMS-10754 - Fast Track Supporting Statement (1).docx CMS-10754 - Fast Track Supporting Statement	IC Document
CMS-10754 - Fast Track Supporting Statement (1).docx CMS-10754 - Fast Track Supporting Statement	IC Document
Round 2 UAT Recruitment email v2.docx Round 2 UAT Recruitment email v2	IC Document
Round 2 UAT Recruitment email v2.docx Round 2 UAT Recruitment email 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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10754	GADCS Feedback Application	GADCS Draft Feedback v2.docx	Yes	Yes	Fillable Fileable
Instruction			GADCS User Guide (1).docx	Yes	No	Printable Only
Form and Instruction	CMS-10754	Observed Testing Protocol	Instrument Testing_Interview Protocol_.docx	Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 60

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	60	60
Annual IC Time Burden (Hours)	120	120
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
CMS-10754 - Fast Track Supporting Statement	CMS-10754 - Fast Track Supporting Statement (1).docx	11/28/2022
Round 2 UAT Recruitment email v2	Round 2 UAT Recruitment email v2.docx	11/28/2022

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