Information Collection

Inpatient Psychiatric Facility Quality Reporting Program

IC 202349 under ICR 201405-0938-003 · OMB 0938-1171.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1171 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10432 Inpatient Psychiatric Facility Quality Reporting Program	Form and Instruction
CMS-10432 IPFQR (Screen Shots) IPF Screen Shots.docx	Form and Instruction
CMS-10432 EHR & Patient Experience (data collection form) EHR & Pt Experience 2016.docx	Form
CMS-10432 TOB & IMM (data collection form) TOB & IMM collection form.docx	Form
CMS-10432 SUB-1 (data collection form) SUB-1 collection form.docx	Form
Crosswalk [rev 5-22-2014 by OSORA PRA].docx Crosswalk	IC Document

IC Title:

Inpatient Psychiatric Facility Quality Reporting Program

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-10432	IPFQR (Screen Shots)	IPF Screen Shots.docx	Yes	Yes	Fillable Printable
Form	CMS-10432	EHR & Patient Experience (data collection form)	EHR & Pt Experience 2016.docx	Yes	Yes	Fillable Printable
Form	CMS-10432	TOB & IMM (data collection form)	TOB & IMM collection form.docx	Yes	Yes	Fillable Printable
Form	CMS-10432	SUB-1 (data collection form)	SUB-1 collection form.docx	Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,626

Number of Respondents for Small Entity: 0

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
	Requested	Program Change Due to New Statute	Previously Approved
Annual Number of Responses for this IC	904,056	307,856	596,200
Annual IC Time Burden (Hours)	2,283,717	4,517	2,279,200
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Crosswalk	Crosswalk [rev 5-22-2014 by OSORA PRA].docx	05/23/2014

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