Submission of Hospice Quality Reporting Program Quality Data using a web based data entry form

Hospice Quality Reporting Program

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Document Name Document Type
Form CMS-10390 Submission of Hospice Quality Reporting Program Quality Data using a web based data entry form Form and Instruction
CMS-10390 Hospice Data Submission Form Hospice QRP DataSubmissionForm_06-28-2012.pdf Form and Instruction
Y1_User_Guide_2012 - REVISED 0209 dates 8-2-12.pdf User Guide for Hospice Quality Reporting Data Collection IC Document
Hospice_QRP_Data_Entry_Tech_Guide_v1.3.pdf Technical User's Guide for Hospice Quality Reporting Data Entry and Submission IC Document

Information Collection (IC) Details

IC Title:	Submission of Hospice Quality Reporting Program Quality Data using a web based data entry form	Agency IC Tracking Number:

Is this a Common Form? No		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-10390	Hospice Data Submission Form	Hospice QRP DataSubmissionForm_06-28-2012.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 3,632	Number of Respondents for Small Entity: 1,700

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

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	3,632	3,632
Annual IC Time Burden (Hours)	657,392	657,392
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
User Guide for Hospice Quality Reporting Data Collection	Y1_User_Guide_2012 - REVISED 0209 dates 8-2-12.pdf	08/07/2012
Technical User's Guide for Hospice Quality Reporting Data Entry and Submission	Hospice_QRP_Data_Entry_Tech_Guide_v1.3.pdf	08/07/2012

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