Information Collection

HQIC Hospital Survey

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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10769 HQIC Hospital Survey	Form and Instruction
Form CMS-10769 HQIIC Hospital Survey 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

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10769				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 %

table that charts list of burden
	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

table that charts IC Documents
Title	Document	Date Uploaded
Crosswalk - Hospital Survey		01/26/2024
Pre-noitification letter for Hospital Survey		01/26/2024
Hospital Follow-up email		01/26/2024

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

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