Information Collection

Quality Measures and Procedures for Hospital Reporting of Quality Data

IC 204350 under ICR 201307-0938-012 · OMB 0938-1022.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1022 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10210 Quality Measures and Procedures for Hospital Reporting of Quality Data	Form and Instruction
CMS-10210 Reconsideration Reqeust Paper Form Four_Page_ReconsiderationRequest_English.docx	Form and Instruction
CMS-10210 Reconsideration Request Online Form Four_Page_ReconsiderationRequest_English.pdf	Form and Instruction
CMS-10210 Hospital Value-Based Program Appeal Request Form HVBP Appeal Request Form_03_2013.pdf	Form and Instruction
CMS-10210 Hospital Value Based Review and Correction Request Form HVBP Review and Corrections Request Form_03_2013.pdf	Form and Instruction
CMS-10210 Hospital Value-Based Purchasing Program Appeal Request F VBP Appeal Request Form_03_2013.doc	Form and Instruction
CMS-10210 Hosptial Value-Based Purchasing Review and Corrections R VBP Review and Corrections Request Form_03_2013.doc	Form and Instruction
CMS-10210 Proposed FY2016 Validation Template for CDI cditemplatedraft.xlsx	Form and Instruction
CMS-10210 Proposed FY2016 Positive Blood Culture Template FY16_CLABSI_BloodCultureTemplate_proposed.xlsx	Form and Instruction
CMS-10210 Proposed FY2016 Positive Urine Culture Template FY16_validation_CAUTI_UrineCultureTemplate_proposed.xlsx	Form and Instruction
CMS-10210 Proposed FY2016 Validation Template for MRSA mrsatemplatedraft.xlsx	Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Quality Measures and Procedures for Hospital Reporting of Quality Data

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

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-10210	Reconsideration Reqeust Paper Form	Four_Page_ReconsiderationRequest_English.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10210	Reconsideration Request Online Form	Four_Page_ReconsiderationRequest_English.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10210	Hospital Value-Based Program Appeal Request Form	HVBP Appeal Request Form_03_2013.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10210	Hospital Value Based Review and Correction Request Form	HVBP Review and Corrections Request Form_03_2013.pdf	No	Yes	Fillable Fileable
Form and Instruction	CMS-10210	Hospital Value-Based Purchasing Program Appeal Request Form	VBP Appeal Request Form_03_2013.doc	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10210	Hosptial Value-Based Purchasing Review and Corrections Request Form	VBP Review and Corrections Request Form_03_2013.doc	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10210	Proposed FY2016 Validation Template for CDI	cditemplatedraft.xlsx	No	No	Fillable Fileable
Form and Instruction	CMS-10210	Proposed FY2016 Positive Blood Culture Template	FY16_CLABSI_BloodCultureTemplate_proposed.xlsx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10210	Proposed FY2016 Positive Urine Culture Template	FY16_validation_CAUTI_UrineCultureTemplate_proposed.xlsx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10210	Proposed FY2016 Validation Template for MRSA	mrsatemplatedraft.xlsx	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 4,400

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: 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	17,600	0	17,600
Annual IC Time Burden (Hours)	6,050,000	-700,000	6,750,000
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
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Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.