Information Collection

Hospital Quality Reporting User Research Participation Interest Survey (CMS-10817 revised)

IC 267561 under ICR 202405-0938-010 · OMB 0938-1397.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10817 Hospital Quality Reporting User Research Participation Interest Survey (CMS-10817 revised)	Form and Instruction
CMS-10817 HQR User Research Participation Survey Revised CMS-10817 Generic Clearance for HQR User Research Participation Survey.docx	Form and Instruction
CMS-10817 HQR User Research Participation Survey Revised CMS-10817 Generic Clearance for HQR User Research Participation Survey.docx	Form and Instruction
Revised CMS-10817 Generic Clearance for HQR User Research Participation Survey.docx Supporting Statement	IC Document
Revised CMS-10817 Generic Clearance for HQR User Research Participation Survey.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-10817	HQR User Research Participation Survey	Revised CMS-10817 Generic Clearance for HQR User Research Participation Survey.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,000

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	2,000	2,000
Annual IC Time Burden (Hours)	67	67
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Supporting Statement	Revised CMS-10817 Generic Clearance for HQR User Research Participation Survey.docx	05/09/2024

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