Quality Measures and Procedures for Hospital Reporting of Quality Data

Hospital Reporting Initiative--Hospital Quality Measures

OMB: 0938-1022

IC ID: 204350

Documents and Forms
Document Name
Document Type
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Information Collection (IC) Details

View Information Collection (IC)

Quality Measures and Procedures for Hospital Reporting of Quality Data
 
No Unchanged
 
Required to Obtain or Retain Benefits
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-10210 Data Accuracy and Completeness Acknowledgemenmt DACAForm2015_Final.doc Yes Yes Fillable Fileable
Form and Instruction CMS-10210 HVBP Review and Corrections Form VBP Review and Corrections Request Form_03_2013.doc Yes Yes Fillable Fileable
Form and Instruction CMS-10210 HVBP Appeal Request Form VBP Appeal Request Form_03_2013.doc Yes Yes Fillable Fileable
Form and Instruction CMS-10210 Validation Template CAUTI Validation TemplateCatheter-Associated Urinary Tract Infection (CAUTI).xlsx Yes Yes Fillable Fileable
Form and Instruction CMS-10210 Validation Template MRSA Validation Template for MRSA.xlsx Yes Yes Fillable Fileable
Form and Instruction CMS-10210 Validation Template CLABSI Validation Template for CLABSI_BloodCultureTemplate.xlsx Yes Yes Fillable Fileable
Form and Instruction CMS-10210 Validation Template CDI Validation Template for CDI.xlsx Yes Yes Fillable Fileable
Form and Instruction CMS-10210 Request for Withholding Data from Public Reporting Request for withholding.doc Yes Yes Fillable Fileable
Form and Instruction CMS-10210 Reconsideration Request Form electronic ReconsiderationRequest_English.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10210 Extroadinary Circumstances Disaster Waiver ExtraordinaryCircumstance_Disaster Waiver.docx Yes Yes Fillable Fileable
Form and Instruction CMS-10210 Healthcare Associated Infection Exception Form HealthcareAssociatedInfection_ExceptionForm.doc Yes Yes Fillable Fileable
Form and Instruction CMS-10210 HVBP Appeal Request Form Screen Shot HVBP Appeal Request Form_03_2013.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10210 HVBP Review and Correction Rquest Form Screen Shot HVBP Review and Corrections Request Form_03_2013.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10210 HIQR Notice of Participation Form Notice of Participation.docx Yes Yes Fillable Fileable
Form and Instruction CMS-10210 Reconsideration Request Form ReconsiderationRequest_English.docx Yes Yes Fillable Fileable

Health Public Health Monitoring

 

4,400 0
   
Private Sector Businesses or other for-profits
 
   100 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 17,600 0 0 0 0 17,600
Annual IC Time Burden (Hours) 6,050,000 0 -700,000 0 0 6,750,000
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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

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