Information Collection

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

IC 203679 under ICR 201403-0938-016 · 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⚠️ Notice: This information collection may be referencing outdated material.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 - Descriptions HQRP Hospice Item Set- Item Descriptions_final.pdf	Form and Instruction
CMS-10390 Hospice Item Set - Admissions HQRP Hospice Item Set Admission_final.pdf	Form and Instruction
CMS-10390 Hospice Item Set - Discharge HQRP Hospice Item Set Discharge_final.pdf	Form and Instruction
Hospice PRA Burden Estimate 08 23 13.docx Burden Calculation Worksheet	IC Document
Changes to Hospice Item Set 12 4 13.pdf Crosswalk	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 - Discharge	HQRP Hospice Item Set Discharge_final.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10390	Hospice Item Set - Descriptions	HQRP Hospice Item Set- Item Descriptions_final.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10390	Hospice Item Set - Admissions	HQRP Hospice Item Set Admission_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: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Change Due to Potential Violation of the PRA
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
Burden Calculation Worksheet	Hospice PRA Burden Estimate 08 23 13.docx	03/25/2014
Crosswalk	Changes to Hospice Item Set 12 4 13.pdf	03/25/2014

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