Information Collection

Quality Payment Program Site Intercept Survey (CMS-10804)

IC 267550 under ICR 202405-0938-010 · OMB 0938-1397.

Documents and Forms

Documents and forms in this information collection
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

IC Title:

Agency IC Tracking Number:

IC Status: New

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-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 %

table that charts list of burden
	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

table that charts IC Documents
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.