View Information Collection (IC)

View Information Collection (IC)

View Information Collection (IC)

IC Title:	(CMS-10776) IPRO 2020 Collaborator Satisfaction Survey-Request for Approval-Nursing Homes	Agency IC Tracking Number:	CCSQ

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10776	Collaoborator Survey Nursing Home	CMS-10776 Draft_2021 Collaborator Survey_Nursing Home_03.22.21.pdf		Yes	Yes	Fillable Fileable

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: 964	Number of Respondents for Small Entity: 48

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

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	964	0	964	0	0	0
Annual IC Time Burden (Hours)	161	0	161	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
CMS-10776 Generic Clearance	CMS-10776 Generic_Clearance_Submission_IPRO - Nursing Home.docx	05/12/2021

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