Quality Payment Program Site Intercept Survey (CMS-10804)

Generic Clearance for the Center for Clinical Standards and Quality IT Product and Support Teams (CMS-10706)

Documents and Forms

Document Name Document Type
Form CMS-10804 Quality Payment Program Site Intercept Survey (CMS-10804) Form and Instruction
CMS-10804 QPP Site Intercept Survey CMS-10804 QPP Site Intercept Survey RFA - 508 Compliant.pdf Form and Instruction
CMS-10804 QPP Site Intercept Survey CMS-10804 QPP Site Intercept Survey RFA - 508 Compliant.pdf Form and Instruction
CMS-10804 QPP Site Intercept Survey RFA - 508 Compliant.docx Supporting Statement IC Document
CMS-10804 QPP Site Intercept Survey RFA - 508 Compliant.docx Supporting Statement IC Document

Information Collection (IC) Details

IC Title:	Quality Payment Program Site Intercept Survey (CMS-10804)	Agency IC Tracking Number:

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-10804	QPP Site Intercept Survey	CMS-10804 QPP Site Intercept Survey RFA - 508 Compliant.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,200	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: 100 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,200	1,200
Annual IC Time Burden (Hours)	100	100
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Supporting Statement	CMS-10804 QPP Site Intercept Survey RFA - 508 Compliant.docx	05/09/2024

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