HQIC Hospital 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 HQIC Hospital Survey Form and Instruction
CMS-10769 HQIIC Hospital Survey CMS-10769_App_B_HQIC_Hospital_Survey_Instrument_062922_508c.docx Form and Instruction
CMS-10769 HQIIC Hospital Survey CMS-10769_App_B_HQIC_Hospital_Survey_Instrument_062922_508c.docx Form and Instruction
CMS-10769_Crosswalk_Hospital_Survey_Questions_(HQIC)_062922_508c.docx Crosswalk - Hospital Survey IC Document
CMS-10769_Crosswalk_Hospital_Survey_Questions_(HQIC)_062922_508c.docx Crosswalk - Hospital Survey IC Document
CMS-10769_App_D.3_Survey_Pre-Notification_Hosp_Communication_10262022_508c.docx Pre-noitification letter for Hospital Survey IC Document
CMS-10769_App_D.3_Survey_Pre-Notification_Hosp_Communication_10262022_508c.docx Pre-noitification letter for Hospital Survey IC Document
CMS-10769_App_D.4_Hospital_follow-up_VM_and_email_10262022_508c.docx Hospital Follow-up email IC Document
CMS-10769_App_D.4_Hospital_follow-up_VM_and_email_10262022_508c.docx Hospital Follow-up email IC Document

Information Collection (IC) Details

IC Title:	HQIC Hospital 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	HQIIC Hospital Survey	CMS-10769_App_B_HQIC_Hospital_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: 275

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
Crosswalk - Hospital Survey	CMS-10769_Crosswalk_Hospital_Survey_Questions_(HQIC)_062922_508c.docx	01/26/2024
Pre-noitification letter for Hospital Survey	CMS-10769_App_D.3_Survey_Pre-Notification_Hosp_Communication_10262022_508c.docx	01/26/2024
Hospital Follow-up email	CMS-10769_App_D.4_Hospital_follow-up_VM_and_email_10262022_508c.docx	01/26/2024

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