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: 0938-1144	ICR Reference No: 202607-0938-003
Status: Active	Previous ICR Reference No: 202404-0938-006
Agency/Subagency: HHS/CMS	Agency Tracking No: OEDA
Title: Application To Be a Qualified Entity to Receive Medicare Data for Performance Measurement / Reapplication / Annual Report Worksheet (CMS-10394)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR: No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 11/10/2026
	Date Received in OIRA: 07/17/2026
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2029	36 Months From Approved	07/31/2027
Responses	70	0	70
Time Burden (Hours)	5,800	0	5,800
Cost Burden (Dollars)	0	0	0

Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
QECP Application, Reapplication, DUA and ARW	CMS-10394, CMS-10394, CMS-10394, CMS-10394, CMS-10394, CMS-10394, CMS-10394, CMS-10394, CMS-10394	, , , , , , , ,

Annual Cost to Federal Government: $466,776

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]? Yes

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: Stephan McKenzie 410 786-1943 stephan.mckenzie@cms.hhs.gov

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