Information Collection

Hospital Restraint/Seclusion Death Report Worksheet

IC 205636 under ICR 201301-0938-009 · OMB 0938-1210.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1210 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10455 Hospital Restraint/Seclusion Death Report Worksheet	Form
CMS-10455 Health Death Report Form Hospital DeathReport Form 22 jan 13 with corrections.doc	Form
CMS-10455 Intake DRS screen print 08092012.docx	Form and Instruction
CMS-10455 Screenshot DRS screens 06142012.docx	Form and Instruction

IC Title:

Hospital Restraint/Seclusion Death Report Worksheet

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 482 section 13

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	CMS-10455	Health Death Report Form	Hospital DeathReport Form 22 jan 13 with corrections.doc	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10455	Intake	DRS screen print 08092012.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10455	Screenshot	DRS screens 06142012.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: Automated Survey Processing Environment (ASPEN) Complaints/Incidents Tracking System (ACTS), System No. 09-70-1519

FR Citation: 71 FR 29644

Number of Respondents: 4,900

Number of Respondents for Small Entity: 4,900

Affected Public: Private Sector

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

Percentage of Respondents Reporting Electronically: 90 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	24,500	24,500
Annual IC Time Burden (Hours)	8,085	8,085
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.