Inpatient Psychiatric Facility Quality Reporting Program

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1171 can be found here:

Documents and Forms

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

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.