NQIIC Nursing Home Survey

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

Documents and Forms

Document Name Document Type
Form CMS-10769 NQIIC Nursing Home Survey Form and Instruction
CMS-10769 NQIIC Nursing Home Survey CMS-10769_App_A_NQIIC_Nursing_Home_Survey_Instrument_062922_508c.docx Form and Instruction
CMS-10769 NQIIC Nursing Home Survey CMS-10769_App_A_NQIIC_Nursing_Home_Survey_Instrument_062922_508c.docx Form and Instruction
CMS-10769_App_D.1_Survey_Pre-Notification_NH_Communication_10262022_508c.docx Survey Pre-notification Letter IC Document
CMS-10769_App_D.1_Survey_Pre-Notification_NH_Communication_10262022_508c.docx Survey Pre-notification Letter IC Document
CMS-10769_App_D.2_Nursing_Home_follow-up_VM_and_email_10262022_508c.docx Nursing Home Follow-up Email IC Document
CMS-10769_App_D.2_Nursing_Home_follow-up_VM_and_email_10262022_508c.docx Nursing Home Follow-up Email IC Document
CMS-10769_Crosswalk_NursingHome_Survey_Questions_(QIN-QIO)_062922_508c.docx Crosswalk of Nursing Home Survey IC Document
CMS-10769_Crosswalk_NursingHome_Survey_Questions_(QIN-QIO)_062922_508c.docx Crosswalk of Nursing Home Survey IC Document
CMS-10769_Crosswalk_NursingHome_Hospital_Survey_Communications_071923_508c.docx Crosswalk of NH Communication IC Document
CMS-10769_Crosswalk_NursingHome_Hospital_Survey_Communications_071923_508c.docx Crosswalk of NH Communication IC Document

Information Collection (IC) Details

IC Title:	NQIIC Nursing Home Survey	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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-10769	NQIIC Nursing Home Survey	CMS-10769_App_A_NQIIC_Nursing_Home_Survey_Instrument_062922_508c.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 500	Number of Respondents for Small Entity: 250

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	500	0	500
Annual IC Time Burden (Hours)	167	2	165
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Survey Pre-notification Letter	CMS-10769_App_D.1_Survey_Pre-Notification_NH_Communication_10262022_508c.docx	01/26/2024
Nursing Home Follow-up Email	CMS-10769_App_D.2_Nursing_Home_follow-up_VM_and_email_10262022_508c.docx	01/26/2024
Crosswalk of Nursing Home Survey	CMS-10769_Crosswalk_NursingHome_Survey_Questions_(QIN-QIO)_062922_508c.docx	01/26/2024
Crosswalk of NH Communication	CMS-10769_Crosswalk_NursingHome_Hospital_Survey_Communications_071923_508c.docx	01/26/2024

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