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Federal forms, ICRs, and supporting documents

Information Collection

HQIC Hospital Survey

IC 248181 under ICR 202401-0938-008 · OMB 0938-1424.

Documents and Forms
Document Name
Document Type
Form and Instruction
Form and Instruction
Form and Instruction
IC Document
IC Document
IC Document
IC Document
IC Document
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Information Collection (IC) Details

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HQIC Hospital Survey
 
No Modified
 
Voluntary
 

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

Health Health Care Services

 

500 275
   
Private Sector Businesses or other for-profits
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 500 0 0 0 0 500
Annual IC Time Burden (Hours) 167 0 2 0 0 165
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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.