Information Collection

Nursing Home survey

IC 192514 under ICR 201004-0938-003 · OMB 0938-1104.

Documents and Forms

Document Name Document Type
Form CMS-10294 Nursing Home survey Form and Instruction
CMS-10294 CMS-10294.QIO Surveys and Letters CMS-10294.QIO Surveys and Letters.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Nursing Home survey	Agency IC Tracking Number:

Is this a Common Form? No		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-10294	CMS-10294.QIO Surveys and Letters	CMS-10294.QIO Surveys and Letters.pdf		No	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,250	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,250	1,250
Annual IC Time Burden (Hours)	413	413
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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