Information Collection Request

Evaluation of the CMS Network of Quality Improvement and Innovation Contractors Program (NQIIC) (CMS-10769)

ICR 202401-0938-008 · OMB 0938-1424 · Active

Forms and Documents

Forms and supporting documents for this ICR
DocumentTypeStatusAvailability
Form CMS-10769 Outpatient Clinicians Online Survey Instrument Form and Instruction New Repair queued
Form CMS-10769 Outpatient Clinician Survey Form and Instruction New Repair queued
Form CMS-10769 HQIIC Hospital Survey Form and Instruction Modified Available
Form CMS-10769 HQIC Hospital Survey Form and Instruction Modified Repair queued
Form CMS-10769 NQIIC Nursing Home Survey Form and Instruction Modified Available
Form CMS-10769 NQIIC Nursing Home Survey Form and Instruction Modified Repair queued
CMS-10769 response to comments 1-11-24.docx Supplementary Document Uploaded 2024-01-25 Repair queued
CMS-10769_Supporting_Statement_B_3-2-2023.docx Supporting Statement B Uploaded 2024-01-25 Repair queued
CMS-10769_Supporting_Statement_A__1-10-24.docx Supporting Statement A Uploaded 2024-01-26 Repair queued

IC Document Collections

Information collection document groups
IC IDCollectionTypeStatusForm
264722 Outpatient Clinician Survey Form and Instruction NewOutpatient Clinicians Online Survey Instrument
264722 Outpatient Clinician Survey Form and Instruction New
248181 HQIC Hospital Survey Form and Instruction ModifiedHQIIC Hospital Survey
248181 HQIC Hospital Survey Form and Instruction Modified
248179 NQIIC Nursing Home Survey Form and Instruction ModifiedNQIIC Nursing Home Survey
248179 NQIIC Nursing Home Survey Form and Instruction Modified

ICR Details

Reginfo record details
table that charts list comparision
  Inventory as of this Action Requested Previously Approved
07/31/2027 36 Months From Approved 07/31/2025
1,900 0 1,000
559 0 330
0 0 0





Reginfo record details
3
table that charts list of burden
IC Title Form No. Form Name
HQIC Hospital Survey CMS-10769
NQIIC Nursing Home Survey CMS-10769
Outpatient Clinician Survey CMS-10769

table that charts list of burden
  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 1,900 1,000 0 900 0 0
Annual Time Burden (Hours) 559 330 0 229 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0


Reginfo record details
  No