View Information Collection (IC)

View Information Collection (IC)

IC Title:	PY 23 QPP Submissions Intercept Survey (CMS-10838)	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-10838	Submissions Intercept Survey Instrument	CMS-10838 Submissions Intercept Survey instrument clean.docx		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10838	Submissions Intercept Survey Instrument	CMS-10838 Submissions Intercept Survey instrument redline.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: 1,500	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	1,500	0	1,500	0	0	0
Annual IC Time Burden (Hours)	125	0	125	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Supporting Statement	CMS-10838 PY23 Submissions Intercept Survey Supporting Statement.docx	12/20/2023

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