View Information Collection Request (ICR) Package

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View ICR - OIRA Conclusion

OMB Control No: 0938-1102	ICR Reference No: 201611-0938-013
Status: Historical Active	Previous ICR Reference No: 201402-0938-005
Agency/Subagency: HHS/CMS	Agency Tracking No: 21419
Title: (CMS-10287) Medicare Quality of Care Complaint Form
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR: No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 05/12/2017
	Date Received in OIRA: 11/23/2016
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2020	36 Months From Approved	05/31/2017
Responses	4,350	0	3,500
Time Burden (Hours)	725	0	583
Cost Burden (Dollars)	0	0	0

ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to Agency Discretion
Annual Number of Responses	4,350	3,500	850
Annual Time Burden (Hours)	725	583	142
Annual Cost Burden (Dollars)	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: There was an increase in the number of complaints. The burden hour increased from 583 to 725.

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