Information Collection

Inpatient Psychiatric Facility Quality Reporting Program

IC 202349 under ICR 201705-0938-005 · 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⚠️ Notice: This information collection may be referencing outdated material.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 Data Accuracy Form CMS IPF DACA Paper Form_FY2020.docx	Form and Instruction
CMS-10432 HBIPS Measures Data Collection Tool CMS IPF HBIPS Data collection paper form_FY2020.docx	Form and Instruction
CMS-10432 Vendor Authorization Form CMS IPF Vendor Auth_paperform_FY2020.docx	Form and Instruction
CMS-10432 Online Data Entry Tool Content for Structural Measures EHR Pt Experience 2019.docx	Form and Instruction
CMS-10432 FY 2019 Non-Measure Data Collection Paper Tool FY 2020 IPF_NonMeasureData_PprTool_.docx	Form and Instruction
CMS-10432 IPF Screen shots IPF Screen Shots_08_02_2016.docx	Form and Instruction
CMS-10432 Notice of Participation IPFQR_NOP_FY2020.pdf	Form and Instruction
CMS-10432 Online Data Entry Tool Content for Web-Based Measure Col Screening for Metabolic Disorders collection form FY 2020.docx	Form and Instruction
CMS-10432 TOB IMM Collection Form TOB IMM collection form FY 2020.docx	Form and Instruction
CMS-10432 Transitions Measures Collection Form Transition Measure collection form FY 2019.docx	Form and Instruction
CMS-10432 Substance Use Measure Collection IPF_FY2020 SUB_form.docx	Form and Instruction

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 Data Accuracy Form	CMS IPF DACA Paper Form_FY2020.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10432	HBIPS Measures Data Collection Tool	CMS IPF HBIPS Data collection paper form_FY2020.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10432	Vendor Authorization Form	CMS IPF Vendor Auth_paperform_FY2020.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10432	Online Data Entry Tool Content for Structural Measures	EHR Pt Experience 2019.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10432	FY 2019 Non-Measure Data Collection Paper Tool	FY 2020 IPF_NonMeasureData_PprTool_.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10432	IPF Screen shots	IPF Screen Shots_08_02_2016.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10432	Notice of Participation	IPFQR_NOP_FY2020.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10432	Online Data Entry Tool Content for Web-Based Measure Collection	Screening for Metabolic Disorders collection form FY 2020.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10432	TOB IMM Collection Form	TOB IMM collection form FY 2020.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10432	Transitions Measures Collection Form	Transition Measure collection form FY 2019.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10432	Substance Use Measure Collection	IPF_FY2020 SUB_form.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,684

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

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

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Previously Approved
Annual Number of Responses for this IC	1,428,032	1,428,032
Annual IC Time Burden (Hours)	4,657,944	4,657,944
Annual IC Cost Burden (Dollars)	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.