Appendix A: CCQM-PC Survey

Care Coordination Quality Measure for Patients in the Primary Care Setting

Documents and Forms

Document Name Document Type
Form 1 Appendix A: CCQM-PC Survey Form and Instruction
1 CCQM-PC Appendix_A_the CCQM-PC survey_UPD2.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Appendix A: CCQM-PC 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	1	CCQM-PC	Appendix_A_the CCQM-PC survey_UPD2.pdf		No		Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 4,500	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	4,500	4,500
Annual IC Time Burden (Hours)	1,875	1,875
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.