View Information Collection (IC)

View Information Collection (IC)

View Information Collection (IC)

IC Title:	IPRO Community of Care Coalitions Collaborator Survey (2023)(CMS-10771)	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-10771	IPRO Partnership for Community Health Coalition Initiative Collaborator Survey (2023)	CMS-10771 Draft_2023 Collaborator Survey_Partnership for CHC.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: 9	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	9	0	9	0	0	0
Annual IC Time Burden (Hours)	2	0	2	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Supporting Statement	CMS-10771 Generic_Clearance_Submission_IPRO - Community of Care Coalitions.docx	07/19/2023
tracked changed version	2022 Collaborator Survey_CCC - tracked changes.docx	07/19/2023

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