MIPS Feedback Request: 8 Quick Multiple Choice Questions (CMS-10683)

Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery (CMS-10415)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1185 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10683 MIPS Feedback Request: 8 Quick Multiple Choice Questions (CMS-10683) Form and Instruction
CMS-10683 MIPS Feedback Request: 8 Quick Multiple Choice Questions CMS-10683. MIPS Feedback Request - 8 Quick Multiple Choice Questions.pdf www.surveymonkey.com/r/KVPZY3Y Form and Instruction
CMS-10683.Generic_Clearance_Submission_Template_MIPS Feedback_.doc CMS-10683.Generic_Clearance_Submission_Template_MIPS Feedback_ IC Document

Information Collection (IC) Details

IC Title:	MIPS Feedback Request: 8 Quick Multiple Choice Questions (CMS-10683)	Agency IC Tracking Number:

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-10683	MIPS Feedback Request: 8 Quick Multiple Choice Questions	CMS-10683. MIPS Feedback Request - 8 Quick Multiple Choice Questions.pdf	https://www.surveymonkey.com/r/KVPZY3Y	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2,793	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	2,793	2,793
Annual IC Time Burden (Hours)	186	186
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
CMS-10683.Generic_Clearance_Submission_Template_MIPS Feedback_	CMS-10683.Generic_Clearance_Submission_Template_MIPS Feedback_.doc	10/04/2018

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