Information Collection

Participation Exemption Request (PER) Form

IC 210204 under ICR 202303-0938-010 · OMB 0938-1066.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1066 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10275 Participation Exemption Request (PER) Form	Form
CMS-10275 Participation Exemption Request (PER) Form Attachment B_HHCAHPS Participation_Exempt_Request Form 12-29-2022.pdf	Form
CMS-10275 Participation Exemption Request (PER) Form Attachment B_HHCAHPS Participation_Exempt_Request Form 12-29-2022.pdf	Form

IC Title:

Participation Exemption Request (PER) Form

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

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	CMS-10275	Participation Exemption Request (PER) Form	Attachment B_HHCAHPS Participation_Exempt_Request Form 12-29-2022.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 700

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
	Approved	Previously Approved
Annual Number of Responses for this IC	700	700
Annual IC Time Burden (Hours)	231	231
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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