Information Collection

CMS Electronic Prescribing of Controlled Substances Intercept Survey Intercept Survey (CMS-10921)

IC 273890 under ICR 202408-0938-002 · OMB 0938-1399.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CmS-10921 Electronic Prescribing of Controlled Substances Intercept Survey CMS Electronic Prescribing of Controlled Substances Intercept Survey Intercept Survey (CMS-10921)	Form and Instruction
CmS-10921 Electronic Prescribing of Controlled Substances Intercep CMS-10921 2024 CMS Electronic Prescribing of Controlled Substances Intercept Survey.docx	Form and Instruction
CMS-10921 2024 EPCS Intercept Survey supporting statement.docx CMS-10921 Supporting Statement	IC Document

IC Title:

Agency IC Tracking Number:

CCSQ

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-10921				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 800

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
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	800	800
Annual IC Time Burden (Hours)	200	200
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
CMS-10921 Supporting Statement		01/28/2025

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

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