Information Collection

Submission of Hospice Quality Reporting Program Quality Data using a web based data entry form

IC 203679 under ICR 201703-0938-002 · OMB 0938-1153.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1153 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10390 Submission of Hospice Quality Reporting Program Quality Data using a web based data entry form	Form and Instruction
CMS-10390 Hospice Item Set - Descriptions CMS-10390 - HQRP Hospice Item Set- Item Descriptions_final wxx.docx	Form and Instruction
CMS-10390 Hospice Item Set v2 Admission CMS-10390 - Hospice Item Set v2 Admission wx.pdf	Form and Instruction
CMS-10390 Hospice Data Set Discharge CMS-10390 - Hospice Item Set v2 Discharge wxx.docx	Form and Instruction
CMS-10390 Exhibit A FY 2017 Hospice PRA Burden Estimate Calculation Worksheet.pdf Burden Calculation Worksheet	IC Document
CMS-10390 - Hospice Item Set V2 Change Table.pdf Crosswalk	IC Document

IC Title:

Submission of Hospice Quality Reporting Program Quality Data using a web based data entry form

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-10390	Hospice Item Set - Descriptions	CMS-10390 - HQRP Hospice Item Set- Item Descriptions_final wxx.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10390	Hospice Item Set v2 Admission	CMS-10390 - Hospice Item Set v2 Admission wx.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10390	Hospice Data Set Discharge	CMS-10390 - Hospice Item Set v2 Discharge wxx.docx	Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 4,259

Number of Respondents for Small Entity: 4,046

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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	4,259	517	3,742
Annual IC Time Burden (Hours)	686,631	160,804	525,827
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Burden Calculation Worksheet	CMS-10390 Exhibit A FY 2017 Hospice PRA Burden Estimate Calculation Worksheet.pdf	04/28/2016
Crosswalk	CMS-10390 - Hospice Item Set V2 Change Table.pdf	04/28/2016

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