Information Collection

Quality Improvement Strategy Implementation Plan and Progress Report Form

IC 217708 under ICR 202408-0938-014 · OMB 0938-1286.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10540 Quality Improvement Strategy Implementation Plan and Progress Report Form	Form and Instruction
CMS-10540 QIS-Implementation-Plan CMS-10540 - 2025 Implementation Plan Form.pdf	Form and Instruction
CMS-10540 QIS-Implementation-Plan CMS-Implementation Plan Form.docx	Form and Instruction
cms-10540 Modification Summary Supplement CMS-10540 - 2025 Modification Summary Supplement Form.pdf	Form and Instruction
cms-10540 Modification Summary Supplement CMS-10540 - Modification Summary Supplement Form.docx	Form and Instruction
CMS-10540 QIS Progress Report CMS-10540 - 2025 Progress Report Form.pdf	Form and Instruction
CMS-10540 QIS Progress Report CMS-10540 - Progress Report Formf.docx	Form and Instruction
CMS- PY2025 Final QIS Technical-Guidance.pdf 2025 Final QIS Technical Guidance	IC Document
CMS- PY2025 Final QIS Technical-Guidance.pdf 2025 Final QIS Technical Guidance	IC Document

IC Title:

Agency IC Tracking Number:

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:

table that charts list of 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-Implementation Plan Form.docx	Yes	Yes	Fillable Fileable
Form and Instruction	cms-10540	Modification Summary Supplement	CMS-10540 - Modification Summary Supplement Form.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10540	QIS Progress Report	CMS-10540 - Progress Report Formf.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 250

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

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

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	250	0	250
Annual IC Time Burden (Hours)	14,880	3,880	11,000
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
2025 Final QIS Technical Guidance	CMS- PY2025 Final QIS Technical-Guidance.pdf	08/14/2024

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