Pressure Ulcer Submissions

Long Term Care Hospital (LCTH) Quality Reporting Program

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1163 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10409 Pressure Ulcer Submissions Form and Instruction
CMS-10409 LTCH Care Data Set Admissions LTCH CARE Data Set_Admission_v2 00_20121120.pdf Form and Instruction
CMS-10409 LTCH Care Data Set Expired LTCH CARE Data Set_Expired_v2 00.pdf Form and Instruction
CMS-10409 LTCH Care Data Set Planned Discharge LTCH CARE Data Set_Planned Discharge_v2 00_20121120.pdf Form and Instruction
CMS-10409 LTCH Care Data Set Unplanned Discharge LTCH CARE Data Set_Unplanned Discharge_v2 00_20121120.pdf Form and Instruction
Appendix B Change Table for PRA_V2 00_20121207.docx Appendix B - Change Table IC Document
Appendix A LTCH CARE Item Matrix_V2 00_20121207.xlsx Appendix A - LTCH Item Matrix IC Document
Burden Calculations LTCH clean 12 19 12.docx Burden Calculations LTCH clean 12 19 12 IC Document

Information Collection (IC) Details

IC Title:	Pressure Ulcer Submissions	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-10409	LTCH Care Data Set Admissions	LTCH CARE Data Set_Admission_v2 00_20121120.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10409	LTCH Care Data Set Expired	LTCH CARE Data Set_Expired_v2 00.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10409	LTCH Care Data Set Planned Discharge	LTCH CARE Data Set_Planned Discharge_v2 00_20121120.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10409	LTCH Care Data Set Unplanned Discharge	LTCH CARE Data Set_Unplanned Discharge_v2 00_20121120.pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 442	Number of Respondents for Small Entity: 200

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	Previously Approved
Annual Number of Responses for this IC	403,988	140,988	263,000
Annual IC Time Burden (Hours)	212,160	168,660	43,500
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Appendix B - Change Table	Appendix B Change Table for PRA_V2 00_20121207.docx	04/12/2013
Appendix A - LTCH Item Matrix	Appendix A LTCH CARE Item Matrix_V2 00_20121207.xlsx	04/12/2013
Burden Calculations LTCH clean 12 19 12	Burden Calculations LTCH clean 12 19 12.docx	04/12/2013

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