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⚠️ Notice: This information collection may be referencing outdated material.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 IPF Screen Shots IPF Screen Shots.docx Form and Instruction
CMS-10432 HBIPS Measures Data Collection Tool CMS IPF HBIPS Data collection paper form_FY2018.docx Form
CMS-10432 Assessment of Patient Experience of Care & Use of an Ele EHR Pt Experience 2018.docx Form
CMS-10432 Screening for Metabolic Disorders Screening for Metabolic Disorders collection form FY 2018.docx Form
Substance Use: SUB CMS-10432 SUB collection form FY2018.docx Form
TOB 1, 2, 2a, 3 an CMS-10432 TOB IMM collection form FY 2018.docx Form
CMS-10432 Transition Record Transfer Measure collection form FY 2018.docx Form

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: Required to Obtain or Retain Benefits

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	IPF Screen Shots	IPF Screen Shots.docx	Yes	Yes	Fillable Printable
Form	CMS-10432	HBIPS Measures Data Collection Tool	CMS IPF HBIPS Data collection paper form_FY2018.docx	Yes	Yes	Fillable Printable
Form	CMS-10432	Assessment of Patient Experience of Care & Use of an Electronic Health Record	EHR Pt Experience 2018.docx	Yes	Yes	Fillable Printable
Form	CMS-10432	Screening for Metabolic Disorders	Screening for Metabolic Disorders collection form FY 2018.docx	Yes	Yes	Fillable Printable
Form	Substance Use: SUB 1, 2, and 2a	CMS-10432	SUB collection form FY2018.docx	Yes	Yes	Fillable Printable
Form	TOB 1, 2, 2a, 3 and 3a, and IMM 2	CMS-10432	TOB IMM collection form FY 2018.docx	Yes	Yes	Fillable Printable
Form	CMS-10432	Transition Record	Transfer Measure collection form FY 2018.docx	Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,617	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	696,927	-207,129	904,056
Annual IC Time Burden (Hours)	139,385	-1,799,620	1,939,005
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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