Information Collection

Inpatient Psychiatric Facility Quality Reporting Program

IC 202349 under ICR 201205-0938-005 · OMB 0938-1171.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1171 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 10432 Participation, Decline to Participate, Withdrawal and Waiver Forms Inpatient Psychiatric Facility Quality Reporting Program	Form and Instruction
Form 10432 Web-based Measure Online Data Entry Tool Content Inpatient Psychiatric Facility Quality Reporting Program	Form
10432 Participation, Decline to Participate, Withdrawal and Wa Appendices_forms.5-1-2012.docx	Form and Instruction
10432 Web-based Measure Online Data Entry Tool Content Data collection.docx	Form
Notification Letter.docx Notification letter	IC Document

IC Title:

Inpatient Psychiatric Facility Quality Reporting Program

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	10432				Yes	Yes	Fillable Printable
Form	10432				Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,741

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

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

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Program Change Due to New Statute
Annual Number of Responses for this IC	471,811	471,811
Annual IC Time Burden (Hours)	1,415,433	1,415,433
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Notification letter		05/01/2012

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

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