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Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
Application and Re-application processes
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Modified
Obligation to Respond:
Voluntary
CFR Citation:
42 CFR 401.703a
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form and Instruction
CMS-10394
Application
QECP_PaperBased_ApplicationForm.pdf
Yes
Yes
Fillable Fileable Signable
Form and Instruction
CMS-10294
QECP MEasure Production QA Worksheet
QECP_MeasureProduction_QA_Worksheet.pdf
Yes
Yes
Fillable Fileable Signable
Form and Instruction
CMS-10394
QECP Measure Information Workbook
QECP_Measure_Information_Workbook.pdf
Yes
Yes
Fillable Fileable Signable
Instruction
QECP_Letter_of_Commitment.pdf
Yes
Yes
Fillable Printable
Form and Instruction
CMS-10394
QECP Data Source Attestation
QECP_DataSource_Attestation.pdf
Yes
Yes
Fillable Fileable Signable
Form and Instruction
CMS-10392
QECP Data Security Workbook
QECP_DataSecurity_Workbook.pdf
Yes
Yes
Fillable Fileable Signable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Health Care Services
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
35
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 %
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
35
0
0
0
0
35
Annual IC Time Burden (Hours)
6,833
0
0
0
0
6,833
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
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.