View Information Collection Request (ICR) Package

Please note that the OMB number and expiration date may not have been determined when this Information Collection Request and associated Information Collection forms were submitted to OMB. The approved OMB number and expiration date may be found by clicking on the Notice of Action link below.

View ICR - OIRA Conclusion

OMB Control No: 0938-1102	ICR Reference No: 202007-0938-009
Status: Historical Active	Previous ICR Reference No: 201611-0938-013
Agency/Subagency: HHS/CMS	Agency Tracking No: CCSQ
Title: Medicare Quality of Care Complaint Form (CMS-10287)
Type of Information Collection: Reinstatement with change of a previously approved collection	Common Form ICR: No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 02/12/2021
	Date Received in OIRA: 08/03/2020
Terms of Clearance: In CMS's next extension, revision, or reinstatement request for this collection, please include the following: 1. An analysis of the feasibility of accepting electronic submission of this form, attending to the provisions of the Government Paperwork Elimination Act; 2. A discussion of potential overlap (if any) between this collection and civil rights/discrimination-related complaint collections, including a discussion of how sociodemographic information in this collection is analyzed and utilized; and 3. A discussion of whether this collection is covered by the Privacy Act of 1974.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/29/2024	36 Months From Approved
Responses	4,350	0	0
Time Burden (Hours)	725	0	0
Cost Burden (Dollars)	0	0	0

Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination. No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination. No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

Agency Contact: Denise King 410 786-1013 Denise.King@cms.hhs.gov

Something went wrong when downloading this file. If you have any questions, please send an email to risc@gsa.gov.