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PPS-exempt Cancer Hosptital Quality Reporitng (PCQR) Program
 
No Modified
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-10431 Oncology Care Measures Paper Submission Data collection Oncology Care Measures Paper Form_Revised 4.17.2014.docx Yes Yes Fillable Fileable
Form and Instruction CMS-10431 SCIP Measures Paper Submission Data Collection Paperbased form SCIP 4.17.2014.docx Yes Yes Fillable Fileable
Form and Instruction CMS-10431 EBRT Pop Sample Application Form EBRT PopSample_application_July_22_2014.docx Yes Yes Fillable Fileable
Form and Instruction CMS-10431 EBRT Paper based Form EBRT_paperbased_July_24_2014.docx Yes Yes Fillable Fileable
Form and Instruction CMS-10431 EBRT Pop Sample paper based Form EBRT_PopSamp_paperbased_ July_22_2014.docx Yes Yes Fillable Fileable
Form and Instruction CMS-10431 EBRT web application Form EBRT_webapplication_July_24_2014.docx Yes Yes Fillable Fileable
Form and Instruction CMS-10431 Oncology Care Measures Pop Sample application Form OCMs PopSample_application_April 17 2014.docx Yes Yes Fillable Fileable
Form and Instruction CMS-10431 OCM Pop Sample paper based Form OCMs_PopSamp_paperbased_ April 17 2014.docx Yes Yes Fillable Fileable
Form and Instruction CMS-10431 SCIP Pop Sample paper based Form SCIP PopSamp_paperbased_April 17 2014.docx Yes Yes Fillable Fileable
Form and Instruction CMS-10431 SCIP Pop Sample Application Form SCIP PopSample_application April 17 2014.docx Yes Yes Fillable Fileable
Form and Instruction CMS-10431 Data Accuracy and Completeness Acknowledgement PCH DACA Form_041714.doc Yes Yes Fillable Fileable
Form and Instruction CMS-10431 Measure Exception Form PCH Measure Exception Form_01022014_updated_04172014.doc Yes Yes Fillable Fileable
Form and Instruction CMS-10431 Notice of Participation form PCH NOP Paper Form_041714.docx Yes Yes Fillable Fileable

Health Health Care Services

 

11 0
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   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 413,556 0 386,283 0 0 27,273
Annual IC Time Burden (Hours) 206,891 0 138,709 0 0 68,182
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
burden estimate PCHQR Burden Estimate_7 24 2014.docx 08/14/2014
Appendix A PCHQR PRA_Appendix A Aug_4_2014.V2.docx 08/14/2014
Appendix B PCHQR PRA_Appendix B.July_24_2014.docx 08/14/2014
Sampling e-mail Sampling .docx 08/14/2014
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.