CMS-10432 TOB & IMM (data collection form)

Inpatient Psychiatric Facility Quality Reporting (IPFQR) Program
Online Data Entry Tool Content for Web-Based Measure Collection

FY 2017 and Subsequent Years

IPFs should complete the form in a fillable PDF format and submit via email to:
[email protected].

C CN Hospital Name

Tobacco Treatment

Tobacco Treatment- TOB-1 Tobacco Use Screening

NUMERATOR 1Q 2015 2Q 2015 3Q 2015 4Q 2015

T he total number of patients who were screened for
tobacco use status within the first three days of admission

DENOMINATOR 1Q 2015 2Q 2015 3Q 2015 4Q 2015

T he number of hospitalized inpatients 18 years of age
and older

Tobacco Treatment- TOB-2 Tobacco Use Treatment Provided or Offered

TOB-2

NUMERATOR 1Q 2015 2Q 2015 3Q 2015 4Q 2015

T he number of patients who received or refused practical
counseling to quit AND received or refused FDA
approved cessation medications during the first three days
after admission

DENOMINATOR 1Q 2015 2Q 2015 3Q 2015 4Q 2015

T he number of hospitalized inpatients 18 years of age and
older identified as current tobacco users

Tobacco Treatment TOB-2a

NUMERATOR 1Q 2015 2Q 2015 3Q 2015 4Q 2015

T he number of patients who received practical counseling
to quit AND received FDA-approved cessation
medications during the first three days after admission

DENOMINATOR 1Q 2015 2Q 2015 3Q 2015 4Q 2015

T he number of hospitalized inpatients 18 years of age and
older identified as current tobacco users

Immunization

Immunization IMM-2 Influenza Immunization

NUMERATOR 1Q 2015 2Q 2015 3Q 2015 4Q 2015

T he number of inpatient discharges who were screened
for influenza vaccine status and were vaccinated prior
to discharge if indicated

DENOMINATOR 1Q 2015 2Q 2015 3Q 2015 4Q 2015

T he number of acute care hospitalized inpatients age
6 months and older discharged during October, November,
December, January, February, or March

PRA DISCLOSURE STATEMENT

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1171. The time required to complete this information collection is estimated to average 10 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850

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