Quality Improvement Strategy Implementation Plan and Progress Report Form (New Issuer)

Quality Improvement Strategy Implementation Plan and Progress Report (CMS-10540)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1286 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10540 Quality Improvement Strategy Implementation Plan and Progress Report Form (New Issuer) Form and Instruction
CMS-10540 QIS-Implementation-Plan CMS-10540 - Implementation_Plan_Form_v5.pdf Form and Instruction
CMS-10540 QIS-Implementation-Plan CMS-10540 - Implementation_Plan_Form_v5.pdf Form and Instruction
cms-10540 Modification Summary Supplement CMS-10540 - Modification_Summary_Supplement_Form_v5.pdf Form and Instruction
cms-10540 Modification Summary Supplement CMS-10540 - Modification_Summary_Supplement_Form_v5.pdf Form and Instruction
CMS-10540 QIS Progress Report CMS-10540 - Progress_Report_Form_v5.pdf Form and Instruction
CMS-10540 QIS Progress Report CMS-10540 - Progress_Report_Form_v5.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Quality Improvement Strategy Implementation Plan and Progress Report Form (New Issuer)	Agency IC Tracking Number:	10540

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 45 CFR 156.1300 45 CFR 156.200(h) 45 CFR 156.200(b)(5)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10540	QIS-Implementation-Plan	CMS-10540 - Implementation_Plan_Form_v5.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	cms-10540	Modification Summary Supplement	CMS-10540 - Modification_Summary_Supplement_Form_v5.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10540	QIS Progress Report	CMS-10540 - Progress_Report_Form_v5.pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 50	Number of Respondents for Small Entity: 0

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

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	50	-200	250
Annual IC Time Burden (Hours)	4,000	-7,000	11,000
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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