CMS-10432 SUB-1 (data collection form)

Inpatient Psychiatric Facility Quality Reporting (IPFQR) Program
Online Data Entry Tool Content for Substance Use Measure Collection

FY 2016 and Subsequent Years

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

C CN Hospital Name

Substance Use- SUB -1 Alcohol Use Screening

NUMERATOR 1Q 2014 2Q 2014 3Q 2014 4Q 2014

T he number of patients who were screened for alcohol use
using a validated screening questionnaire for unhealthy
drinking within the first three days of admission

DENOMINATOR 1Q 2014 2Q 2014 3Q 2014 4Q 2014

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

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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