Pressure Ulcer Submissions

Long Term Care Hospital (LCTH) Quality Reporting Program

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1163 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10409 Pressure Ulcer Submissions Form and Instruction
CMS-10409 LTCH CARE Data Set_Planned Discharge_v1.01 LTCH CARE Data Set_Planned Discharge_v1.01.pdf Form and Instruction
CMS-10409 LTCH CARE Data Set_Unplanned Discharge_v1.01 LTCH CARE Data Set_Unplanned Discharge_v1.01.pdf Form and Instruction
CMS-10409 LTCH CARE Data Set_Admission_v1.01 LTCH CARE Data Set_Admission_v1.01.pdf Form and Instruction
CMS-10409 LTCH CARE Data Set_Expired_v1.01 LTCH CARE Data Set_Expired_v1.01.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Pressure Ulcer Submissions	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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10409	LTCH CARE Data Set_Planned Discharge_v1.01	LTCH CARE Data Set_Planned Discharge_v1.01.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10409	LTCH CARE Data Set_Unplanned Discharge_v1.01	LTCH CARE Data Set_Unplanned Discharge_v1.01.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10409	LTCH CARE Data Set_Admission_v1.01	LTCH CARE Data Set_Admission_v1.01.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10409	LTCH CARE Data Set_Expired_v1.01	LTCH CARE Data Set_Expired_v1.01.pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 435	Number of Respondents for Small Entity: 200

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

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	263,000	263,000
Annual IC Time Burden (Hours)	43,500	43,500
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.