Information Collection

Hospice Voluntary Quality Data Reporting Form

IC 200291 under ICR 201208-0938-005 · OMB 0938-1153.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1153 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10390 Hospice Voluntary Quality Data Reporting Form	Form and Instruction
CMS-10390 User Guide for Hospice Quality Reporting Data Entry Site HospiceQualityReporting-UserGuide.pdf	Form and Instruction

IC Title:

Hospice Voluntary Quality Data Reporting Form

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Removed

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	CMS-10390	User Guide for Hospice Quality Reporting Data Entry Site	HospiceQualityReporting-UserGuide.pdf		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,766

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
	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	-1,766	1,766
Annual IC Time Burden (Hours)	-442	442
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.