Information Collection

Small Health Care Provider Quality Improvement Program Performance Improvement and Measurement System

IC 211726 under ICR 202506-0906-003 · OMB 0906-0102.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Small Health Care Provider Quality Improvement Program Performance Improvement and Measurement System	Form and Instruction
Form 1 PIMS Measures - SHCPQI Small Health Care Provider Quality Improvement Program Performance Improvement and Measurement System	Form and Instruction
FORHP 0906-0102 - SHCPQI Program Measures (redline) 062625.docx	Other-Redline
FORHP 0906-0102 - SHCPQI Program Measures (redline) 062625.docx	Other-Redline
1 PIMS Measures - SHCPQI FORHP 0906-0102 - SHCPQI Program Measures (clean) 062625.docx	Form and Instruction
1 PIMS Measures - SHCPQI FORHP 0906-0102 - SHCPQI Program Measures (clean) 062625.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

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	1				Yes	Yes	Fillable Fileable
Other-Redline					Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 21

Number of Respondents for Small Entity: 21

Affected Public: Private Sector

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

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	21	21
Annual IC Time Burden (Hours)	284	284
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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

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