PQRS Data Validation Project Electronic Survey

(CMS-10519) Physician Quality Reporting System and the Electronic Prescribing Incentive Program Data Assessment, Accuracy and Improper Payments Identification Support

Documents and Forms

Document Name Document Type
Form CMS-10519 PQRS Data Validation Project Electronic Survey Form and Instruction
CMS-10519 Attachment D - Survey PQRS Data Validation Electronic Survey - Att-D-Survey_OY1_20150126.docx Form and Instruction
PQRS Data Validation Electronic Survey - Att-C-Recruitment_OY1_20150126.docx Attachment C - Survey Invitation IC Document
PSV Information Paper - Awareness (Final 06052015).docx Primary Source Verification Paper IC Document

Information Collection (IC) Details

IC Title:	PQRS Data Validation Project Electronic Survey	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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-10519	Attachment D - Survey	PQRS Data Validation Electronic Survey - Att-D-Survey_OY1_20150126.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 115	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	Previously Approved
Annual Number of Responses for this IC	115	115
Annual IC Time Burden (Hours)	173	173
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Attachment C - Survey Invitation	PQRS Data Validation Electronic Survey - Att-C-Recruitment_OY1_20150126.docx	02/09/2016
Primary Source Verification Paper	PSV Information Paper - Awareness (Final 06052015).docx	02/09/2016

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