Health Equity award Nominations

CMS Health Equity Award – Call for Nominations (CMS-10866)

Documents and Forms

Document Name Document Type
Form CMS-10866 Health Equity award Nominations Form and Instruction
CMS-10866 CMS Health Equity Nomination Form CMSHealthEquityNominationForm_Clean.pdf Form and Instruction
CMS-10866 CMS Health Equity Nomination Form CMSHealthEquityNominationForm_Clean.pdf Form and Instruction
CMS-10866 CMS Health Equity Scoring Rubric CMS Health Equity Award 2020_scoring rubric and worksheet_Clean.pdf Form and Instruction
CMS-10866 CMS Health Equity Scoring Rubric CMS Health Equity Award 2020_scoring rubric and worksheet_Clean.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Health Equity award Nominations	Agency IC Tracking Number:

Is this a Common Form? No		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-10866	CMS Health Equity Nomination Form	CMSHealthEquityNominationForm_Clean.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10866	CMS Health Equity Scoring Rubric	CMS Health Equity Award 2020_scoring rubric and worksheet_Clean.pdf		Yes	Yes	Fillable Printable

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: Federal Government

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	50	50
Annual IC Time Burden (Hours)	100	100
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.