OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

Electronic Visit Verification (EVV) Compliance Survey

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

Documents and Forms
Document Name
Document Type
Form
Form
Instruction
Instruction
Form
Form
Form
Form
Information Collection (IC) Details

View Information Collection (IC)

Electronic Visit Verification (EVV) Compliance Survey
 
No Modified
 
Mandatory
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Instruction CMS-10680 - EVV-Compliance-Survey-Instructions (2018 version 1) (1).pdf Yes Yes Fillable Fileable
Form CMS-10680 EVV Home Health Care Services (HHCS) Survey Electronic Visit Verification (EVV) Compliance Survey Form - HHCS.pdf Yes Yes Fillable Fileable
Form CMS-10680 EVV Personal Care Services (PCS) Survey Electronic Visit Verification (EVV) Compliance Survey Form - PCS.pdf Yes Yes Fillable Fileable

Health Health Care Services

 

10 0
   
State, Local, and Tribal Governments
 
   100 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 20 0 -148 0 0 168
Annual IC Time Burden (Hours) 20 0 -232 0 0 252
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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