Information Collection

Inpatient Psychiatric Facility Quality Reporting Program

IC 202349 under ICR 201505-0938-001 · 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⚠️ Notice: This information collection may be referencing outdated material.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 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

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:

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	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 %

table that charts list of burden
	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

table that charts IC Documents
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.