View Information Collection (IC)

View Information Collection (IC)

View Information Collection (IC)

IC Title:	13th Statement of Work (SoW) Quality Improvement Network-Quality Improvement Organization (QIN-QIO) and American Indian/Alaska Native (AIAN-QIO) Provider Experience Encounter Survey (CMS-10919)	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-10919	13th SOW Rapid Cycle Experience Survey	CMS 10919_13th SOW Rapid Cycle Provider Experience Survey.docx		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10919	13th SOW QIN-QIO Focused QIO Service (FQS) Experience Survey	CMS 10919_13th SOW FQS Experience Survey.docx		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: 26,003	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	26,003	0	26,003	0	0	0
Annual IC Time Burden (Hours)	7,534	0	7,534	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Supporting Statement	CMS-10919 Generic Clearance QIO Experience Surveys Clean 18 Feb 2025.docx	06/17/2025

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