Inpatient Psychiatric Facility Quality Reporting Program

Inpatient Psychiatric Facility Quality Reporting Program (CMS-10432)

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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

Information Collection (IC) Details

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:

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 %

	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

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.