Information Collection

Inpatient Psychiatric Facility Quality Reporting Program

IC 202349 under ICR 201209-0938-003 · 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⚠️ Notice: This information collection may be referencing outdated material.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 CMS-10432 Inpatient Psychiatric Facility Quality Reporting Program	Form and Instruction
CMS-10432 Data Collection Data collection.July_21_2012.docx	Form and Instruction
CMS-10432 Notice of Participation IPFQR_NOP form.Aug_26_2012.revised.V1.0.docx	Form and Instruction
CMS-10432 Data Accuracy and Completeness IPFQR.DACA form.Aug_27_2012.docx	Form and Instruction
CMS-10432 Decline to Participate IPFQR_Decline to participate form_Aug_26_2012.docx	Form and Instruction
CMS-10432 Withdrawal Withdrawalform.Aug_24_2012.docx	Form and Instruction
CMS-10432 Reconsideration Request ReconsiderationRequestPaper Form.Aug_24_2012.docx	Form and Instruction
IPFQR_Notification Letter_Aug_26_2012.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: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10432	Withdrawal	Withdrawalform.Aug_24_2012.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10432	Reconsideration Request	ReconsiderationRequestPaper Form.Aug_24_2012.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10432	Data Collection	Data collection.July_21_2012.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10432	Notice of Participation	IPFQR_NOP form.Aug_26_2012.revised.V1.0.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10432	Data Accuracy and Completeness	IPFQR.DACA form.Aug_27_2012.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10432	Decline to Participate	IPFQR_Decline to participate form_Aug_26_2012.docx	Yes	Yes	Fillable Fileable

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
	Approved	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	IPFQR_Notification Letter_Aug_26_2012.docx	09/05/2012

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