Hospital Restraint/Seclusion Death Report Worksheet

Report of a Hospital Dealth Associated with Restraint or Seclusion

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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

Information Collection (IC) Details

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:

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 %

	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

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.