Information Collection

IPRO Community of Care Coalitions Collaborator Survey (2023)(CMS-10771)

IC 261140 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 Partnership for Community Health Coalition Initiative Collaborator Survey (2023) IPRO Community of Care Coalitions Collaborator Survey (2023)(CMS-10771)	Form and Instruction
CMS-10771 IPRO Partnership for Community Health Coalition Initiati CMS-10771 Draft_2023 Collaborator Survey_Partnership for CHC.pdf	Form and Instruction
CMS-10771 Generic_Clearance_Submission_IPRO - Community of Care Coalitions.docx Supporting Statement	IC Document
2022 Collaborator Survey_CCC - tracked changes.docx tracked changed version	IC Document

IC Title:

Agency IC Tracking Number:

CCSQ

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				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 9

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
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	9	9
Annual IC Time Burden (Hours)	2	2
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Supporting Statement		07/19/2023
tracked changed version		07/19/2023

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

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