Information Collection

? 495.24(d)-Objectives/Measures (EPs)

IC 216075 under ICR 202007-0938-004 · OMB 0938-1278.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1278 can be found here:

Documents and Forms

Document Name Document Type
UserGuide_QNetHospitalRegistrationAttestation.pdf Instruction
CMS-10552 Online Attestation Forms Promoting Interoperability Online Attestation Forms_Screenshots.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	§ 495.24(d)-Objectives/Measures (EPs)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 495.24

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			UserGuide_QNetHospitalRegistrationAttestation.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10552	Online Attestation Forms	Promoting Interoperability Online Attestation Forms_Screenshots.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 30,000	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	30,000	-50,000	80,000
Annual IC Time Burden (Hours)	222,900	-371,500	594,400
Annual IC Cost Burden (Dollars)	0	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.