CMS-10432 TOB IMM Collection Form

Inpatient Psychiatric Facility Quality Reporting (IPFQR) Program
Online Data Entry Tool Content for Web-Based Measure Collection

FY 2020 and Subsequent Years

IPFs should complete the form in a fillable PDF format and submit via email to: [email protected].

C CN Facility Name

Tobacco Treatment

TOB-1 Tobacco Use Screening

NUMERATOR CY 2018

T he total number of patients who were screened for

tobacco use status within the first three days of admission

DENOMINATOR CY 2018

T he number of hospitalized inpatients 18 years of age

and older

TOB-2 Tobacco Use Treatment Provided or Offered

NUMERATOR CY 2018

T he number of patients who received or refused practical

counseling to quit AND received or refused FDA

approved cessation medications during the first three days

after admission

DENOMINATOR CY 2018

T he number of hospitalized inpatients 18 years of age and

older identified as current tobacco users

TOB-2a Tobacco Use Treatment

NUMERATOR CY 2018

T he number of patients who received practical counseling

to quit AND received FDA-approved cessation

medications during the first three days after admission

DENOMINATOR CY 2018

T he number of hospitalized inpatients 18 years of age and

older identified as current tobacco users

TOB-3: Tobacco Use Treatment Provided or Offered at Discharge

NUMERATOR CY 2018

The number of patients who received or refused evidence-based

outpatient counseling AND received or refused a prescription for

FDA-approved cessation medication at discharge

DENOMINATOR CY 2018

T he number of hospitalized inpatients 18 years of age

and older identified as current tobacco users

TOB-3a Tobacco Use Treatment at Discharge

NUMERATOR CY 2018

The number of patients who were referred to evidence-based

outpatient counseling AND received a prescription for FDA-approved

cessation medication at discharge

DENOMINATOR CY 2018

T he number of hospitalized inpatients 18 years of age

and older identified as current tobacco users

Immunization

IMM-2 Influenza Immunization

NUMERATOR CY 2018

T he number of inpatient discharges who were screened

for influenza vaccine status and were vaccinated prior

to discharge if indicated

DENOMINATOR CY 2018

T he number of acute care hospitalized inpatients age

6 months and older discharged during October, November,

December, January, February, or March

PRA DISCLOSURE STATEMENT

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1171 (current expiration: 7/31/2019). The time required to complete this information collection is estimated to average 10 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850

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