Information Collection

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

IC 203679 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⚠️ Notice: This information collection may be referencing outdated material.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 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

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:

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	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 %

table that charts list of burden
	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

table that charts IC Documents
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.