Information Collection

Electronic Visit Verification (EVV) Compliance Survey

IC 235002 under ICR 202509-0938-030 · OMB 0938-1360.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10680 EVV Home Health Care Services (HHCS) Survey Electronic Visit Verification (EVV) Compliance Survey	Form
Form CMS-10680 EVV Personal Care Services (PCS) Survey Electronic Visit Verification (EVV) Compliance Survey	Form
CMS-10680 - EVV-Compliance-Survey-Instructions (2018 version 1) (1).pdf	Instruction
CMS-10680 - EVV-Compliance-Survey-Instructions (2018 version 1) (1).pdf	Instruction
CMS-10680 EVV Home Health Care Services (HHCS) Survey Electronic Visit Verification (EVV) Compliance Survey Form - HHCS.pdf	Form
CMS-10680 EVV Home Health Care Services (HHCS) Survey Electronic Visit Verification (EVV) Compliance Survey Form - HHCS.pdf	Form
CMS-10680 EVV Personal Care Services (PCS) Survey Electronic Visit Verification (EVV) Compliance Survey Form - PCS.pdf	Form
CMS-10680 EVV Personal Care Services (PCS) Survey Electronic Visit Verification (EVV) Compliance Survey Form - PCS.pdf	Form

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction		Yes	Yes	Fillable Fileable
Form	CMS-10680	Yes	Yes	Fillable Fileable
Form	CMS-10680	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 10

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	20	-148	168
Annual IC Time Burden (Hours)	20	-232	252
Annual IC Cost Burden (Dollars)	0	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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