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OMB Control No: 0938-1102	ICR Reference No: 202602-0938-021
Status: Received in OIRA	Previous ICR Reference No: 202007-0938-009
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	Date Submitted to OIRA: 03/02/2026

	Requested	Previously Approved
Expiration Date	36 Months From Approved
Responses	3,369	0
Time Burden (Hours)	562	0
Cost Burden (Dollars)	0	0

ICR Summary of Burden

	Total Request	Change Due to Agency Discretion	Change Due to Potential Violation of the PRA
Annual Number of Responses	3,369	-981	4,350
Annual Time Burden (Hours)	562	-163	725
Annual Cost Burden (Dollars)	0	0	0

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

Burden Increase Due to:

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

Burden Reduction Due to: Miscellaneous Actions

Short Statement: The number of respondents decreased from 4,350 to 3,369. The annual burden hours have decreased from 725 to 562.

Annual Cost to Federal Government: $1,490

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

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