Information Collection Request

Inpatient Psychiatric Facility Quality Reporting Program

ICR 201310-0938-011 · OMB 0938-1171 · Historical Active

Forms and Documents

Forms and supporting documents for this ICR
DocumentTypeStatusAvailability
Form CMS-10432 Inpatient Psychiatric Facility Quality Reporting Program Form and Instruction Modified Available
IPFQR_Notification Letter_Aug_26_2012.docx Supplementary Document Uploaded 2013-10-30 Available
CMS IPF Crosswalk_508.pdf Supplementary Document Uploaded 2013-10-30 Available
CMS IPF Supporting Statement A_updated on 2013_04_01_508.pdf Supporting Statement A Uploaded 2013-10-30 Repair queued

IC Document Collections

Information collection document groups
IC IDCollectionTypeStatusForm
202349 Inpatient Psychiatric Facility Quality Reporting Program Form and Instruction Modified

ICR Details

Reginfo record details
table that charts list comparision
  Inventory as of this Action Requested Previously Approved
02/28/2017 36 Months From Approved 12/31/2015
596,200 0 471,811
2,279,200 0 1,415,433
0 0 0





Reginfo record details
1
table that charts list of burden
IC Title Form No. Form Name
Inpatient Psychiatric Facility Quality Reporting Program CMS-10432, CMS-10432, CMS-10432, CMS-10432, CMS-10432, CMS-10432, CMS-10432, CMS-10432, CMS-10432, CMS-10432, CMS-10432, CMS-10432 Reconsideration Request Form ,   Data Accuracy and Completeness ,   Data Accuracy and Completeness Screen Shot ,   HBIS Structural Measure Data Collection ,   HBIPS-2 Measure Screen Shot ,   Decline to Participate ,   Extroadinary Circumstance/Waiver Request Form ,   Notice of Partication Screen Shot ,   Notice of Participation ,   Vendor Authorization Screen Shot ,   Vendor Authorization ,   Withdrawal of Participation

table that charts list of burden
  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 596,200 471,811 0 124,389 0 0
Annual Time Burden (Hours) 2,279,200 1,415,433 0 863,767 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0


Reginfo record details
  No