Information Collection

Quality Measures and Procedures for Hospital Reporting of Quality Data

IC 204350 under ICR 201402-0938-012 · 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⚠️ Notice: This information collection may be referencing outdated material.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 Data Accuracy and Completeness Acknowledgemenmt DACAForm2015_Final.doc	Form and Instruction
CMS-10210 HVBP Review and Corrections Form VBP Review and Corrections Request Form_03_2013.doc	Form and Instruction
CMS-10210 HVBP Appeal Request Form VBP Appeal Request Form_03_2013.doc	Form and Instruction
CMS-10210 Validation Template CAUTI Validation TemplateCatheter-Associated Urinary Tract Infection (CAUTI).xlsx	Form and Instruction
CMS-10210 Validation Template MRSA Validation Template for MRSA.xlsx	Form and Instruction
CMS-10210 Validation Template CLABSI Validation Template for CLABSI_BloodCultureTemplate.xlsx	Form and Instruction
CMS-10210 Validation Template CDI Validation Template for CDI.xlsx	Form and Instruction
CMS-10210 Request for Withholding Data from Public Reporting Request for withholding.doc	Form and Instruction
CMS-10210 Reconsideration Request Form electronic ReconsiderationRequest_English.pdf	Form and Instruction
CMS-10210 Extroadinary Circumstances Disaster Waiver ExtraordinaryCircumstance_Disaster Waiver.docx	Form and Instruction
CMS-10210 Healthcare Associated Infection Exception Form HealthcareAssociatedInfection_ExceptionForm.doc	Form and Instruction
CMS-10210 HVBP Appeal Request Form Screen Shot HVBP Appeal Request Form_03_2013.pdf	Form and Instruction
CMS-10210 HVBP Review and Correction Rquest Form Screen Shot HVBP Review and Corrections Request Form_03_2013.pdf	Form and Instruction
CMS-10210 HIQR Notice of Participation Form Notice of Participation.docx	Form and Instruction
CMS-10210 Reconsideration Request Form ReconsiderationRequest_English.docx	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	Data Accuracy and Completeness Acknowledgemenmt	DACAForm2015_Final.doc	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10210	HVBP Review and Corrections Form	VBP Review and Corrections Request Form_03_2013.doc	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10210	HVBP Appeal Request Form	VBP Appeal Request Form_03_2013.doc	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10210	Validation Template CAUTI	Validation TemplateCatheter-Associated Urinary Tract Infection (CAUTI).xlsx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10210	Validation Template MRSA	Validation Template for MRSA.xlsx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10210	Validation Template CLABSI	Validation Template for CLABSI_BloodCultureTemplate.xlsx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10210	Validation Template CDI	Validation Template for CDI.xlsx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10210	Request for Withholding Data from Public Reporting	Request for withholding.doc	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10210	Reconsideration Request Form electronic	ReconsiderationRequest_English.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10210	Extroadinary Circumstances Disaster Waiver	ExtraordinaryCircumstance_Disaster Waiver.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10210	Healthcare Associated Infection Exception Form	HealthcareAssociatedInfection_ExceptionForm.doc	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10210	HVBP Appeal Request Form Screen Shot	HVBP Appeal Request Form_03_2013.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10210	HVBP Review and Correction Rquest Form Screen Shot	HVBP Review and Corrections Request Form_03_2013.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10210	HIQR Notice of Participation Form	Notice of Participation.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10210	Reconsideration Request Form	ReconsiderationRequest_English.docx	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
No associated records found

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