Submission of Hospice Quality Reporting Program Quality Data using a web based data entry form

Hospice Item Set

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1153 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10390 Submission of Hospice Quality Reporting Program Quality Data using a web based data entry form Form and Instruction
CMS-10390 Hospice Item Set - Admission HQRP Hospice Item Set Admission_final.pdf Form and Instruction
CMS-10390 Hospice Item Set HQRP Hospice Item Set- Item Descriptions_final.pdf Form and Instruction
CMS-10390 Crosswalk Exhibit E - Changes to HQRP Data Submission form (draft).docx Form and Instruction
CMS-10390 Hospice Item Set - Discharge HQRP Hospice Item Set Discharge_final.pdf Form and Instruction
Y1_User_Guide_2012 - REVISED 0209 dates 8-2-12.pdf User Guide for Hospice Quality Reporting Data Collection IC Document
Hospice_QRP_Data_Entry_Tech_Guide_v1.3.pdf Technical User's Guide for Hospice Quality Reporting Data Entry and Submission IC Document
Hospice PRA Burden Estimate.03.27.13.docx Hospice Burden Estimate IC Document
Exhibit B - Burden Calculations from 2013 Hospice Rule PRA Package (draft).docx Exhibit B- Burden Calculation from 2013 IC Document

Information Collection (IC) Details

IC Title:	Submission of Hospice Quality Reporting Program Quality Data using a web based data entry form	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-10390	Hospice Item Set - Admission	HQRP Hospice Item Set Admission_final.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10390	Hospice Item Set	HQRP Hospice Item Set- Item Descriptions_final.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10390	Crosswalk	Exhibit E - Changes to HQRP Data Submission form (draft).docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10390	Hospice Item Set - Discharge	HQRP Hospice Item Set Discharge_final.pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 3,742	Number of Respondents for Small Entity: 3,555

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

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	3,742	110	3,632
Annual IC Time Burden (Hours)	525,827	-131,565	657,392
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
User Guide for Hospice Quality Reporting Data Collection	Y1_User_Guide_2012 - REVISED 0209 dates 8-2-12.pdf	08/07/2012
Technical User's Guide for Hospice Quality Reporting Data Entry and Submission	Hospice_QRP_Data_Entry_Tech_Guide_v1.3.pdf	08/07/2012
Hospice Burden Estimate	Hospice PRA Burden Estimate.03.27.13.docx	05/28/2013
Exhibit B- Burden Calculation from 2013	Exhibit B - Burden Calculations from 2013 Hospice Rule PRA Package (draft).docx	05/28/2013

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