Information Collection

Inpatient Psychiatric Facility Quality Reporting Program

IC 202349 under ICR 201305-0938-022 · 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⚠️ Notice: This information collection may be referencing outdated material.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 Reconsideration Request Form CMS IPF Recon Request Paper Form_final_508.pdf	Form and Instruction
CMS-10432 Data Accuracy and Completeness CMS IPF DACA Paper Form_final_508.pdf	Form and Instruction
CMS-10432 Data Accuracy and Completeness Screen Shots CMS IPF DACA Screen shots_final_508.pdf	Form and Instruction
CMS-10432 HBIS Structural Measure Data Collection CMS IPF Data collection paper form_final.pdf	Form and Instruction
CMS-10432 HBIPS-2 Measure Screen Shot CMS IPF Data collection_screen shots_final_508.pdf	Form and Instruction
CMS-10432 Decline to Participate CMS IPF Decline to Participate form_final_508.pdf	Form and Instruction
CMS-10432 Extroadinary Circumstance/Waiver Request Form CMS IPF Extraordinary Circumstance Paper Form_final_508.pdf	Form and Instruction
CMS-10432 Notice of Participation Screen Shot CMS IPF NoP screen shots_final_508.pdf	Form and Instruction
CMS-10432 Notice of Participation CMS IPF NoP_final_508.pdf	Form and Instruction
CMS-10432 Vendor Authorization Screen Shot CMS IPF Vendor Auth Screen Shots_final_508.pdf	Form and Instruction
CMS-10432 Vendor Authorization CMS IPF Vendor Authorization_Paperform_Final.pdf	Form and Instruction
CMS-10432 Withdrawal of Participation CMS IPF Withdrawal form_paper_final.pdf	Form and Instruction
IPFQR_Notification Letter_Aug_26_2012.docx Notification Letter	IC Document
CMS IPF Crosswalk.docx Crosswalk	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:

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	Data Accuracy and Completeness Screen Shots	CMS IPF DACA Screen shots_final_508.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10432	HBIS Structural Measure Data Collection	CMS IPF Data collection paper form_final.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10432	HBIPS-2 Measure Screen Shot	CMS IPF Data collection_screen shots_final_508.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10432	Decline to Participate	CMS IPF Decline to Participate form_final_508.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10432	Extroadinary Circumstance/Waiver Request Form	CMS IPF Extraordinary Circumstance Paper Form_final_508.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10432	Notice of Participation Screen Shot	CMS IPF NoP screen shots_final_508.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10432	Notice of Participation	CMS IPF NoP_final_508.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10432	Vendor Authorization Screen Shot	CMS IPF Vendor Auth Screen Shots_final_508.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10432	Vendor Authorization	CMS IPF Vendor Authorization_Paperform_Final.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10432	Withdrawal of Participation	CMS IPF Withdrawal form_paper_final.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10432	Reconsideration Request Form	CMS IPF Recon Request Paper Form_final_508.pdf	No	No	Fillable Fileable
Form and Instruction	CMS-10432	Data Accuracy and Completeness	CMS IPF DACA Paper Form_final_508.pdf	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,200

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

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

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	596,200	124,389	471,811
Annual IC Time Burden (Hours)	2,279,200	863,767	1,415,433
Annual IC Cost Burden (Dollars)	0	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
Crosswalk	CMS IPF Crosswalk.docx	05/28/2013

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