Outpatient Clinician 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 Outpatient Clinician Survey Form and Instruction
CMS-10769 Outpatient Clinicians Online Survey Instrument CMS-10769_App_C_Outpatient Clinicians Survey_062922_508c.docx Form and Instruction
CMS-10769 Outpatient Clinicians Online Survey Instrument CMS-10769_App_C_Outpatient Clinicians Survey_062922_508c.docx Form and Instruction
CMS-10769_App_D.5_Survey_Pre-Notification_OP Clinician_Communication_10262022_508c.docx Pre-Notification Communication Outpatient Clinician Letter IC Document
CMS-10769_App_D.5_Survey_Pre-Notification_OP Clinician_Communication_10262022_508c.docx Pre-Notification Communication Outpatient Clinician Letter IC Document
CMS-10769_App_D.6_OP_Clinicians_follow-up_VM_and_email_062922_508c.docx Voicemail and Email Messages for Outpatient Clinicians IC Document
CMS-10769_App_D.6_OP_Clinicians_follow-up_VM_and_email_062922_508c.docx Voicemail and Email Messages for Outpatient Clinicians IC Document

Information Collection (IC) Details

IC Title:	Outpatient Clinician Survey	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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	Outpatient Clinicians Online Survey Instrument	CMS-10769_App_C_Outpatient Clinicians Survey_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: 900	Number of Respondents for Small Entity: 450

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	900	900
Annual IC Time Burden (Hours)	225	225
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Pre-Notification Communication Outpatient Clinician Letter	CMS-10769_App_D.5_Survey_Pre-Notification_OP Clinician_Communication_10262022_508c.docx	01/26/2024
Voicemail and Email Messages for Outpatient Clinicians	CMS-10769_App_D.6_OP_Clinicians_follow-up_VM_and_email_062922_508c.docx	01/26/2024

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