Information Collection

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

IC 203679 under ICR 201307-0938-020 · OMB 0938-1153.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
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

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:

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-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 %

table that charts list of burden
	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

table that charts IC Documents
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.