View Information Collection (IC)

View Information Collection (IC)

IC Title:	Hospital Survey for Specified Covered Outpatient Drugs (SCODs)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10709	Drug Survey	SurveyWorksheet_CMS_ (4-23-20).xlsx		Yes	Yes	Fillable Printable
Form and Instruction	CMS-10709	Instruction Sheet for Collecting Acquisition Costs	CMS-10709.Survey Instruction Clean (4-23-20).docx		Yes	Yes	Fillable Printable

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: 1,408	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

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	1,408	1,408	0	0	0	0
Annual IC Time Burden (Hours)	67,584	67,584	0	0	0	0
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.