Information Collection

Hospital Restraint/Seclusion Death Report Worksheet

IC 205636 under ICR 201802-0938-002 · OMB 0938-1210.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1210 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10455 Hospital Restraint/Seclusion Death Report Worksheet	Form and Instruction
Instructions for completing CMS 10455 508 Aug 2017.pdf	Instruction
CMS-10455 Health Death Report Form CMS-10455-AUG2017-Final. 02.06.2018.pdf	Form and Instruction
CMS 10455 crosswalk 8.8.17.pdf Crosswalk	IC Document

IC Title:

Hospital Restraint/Seclusion Death Report Worksheet

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 482 section 13

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10455	Health Death Report Form	CMS-10455-AUG2017-Final. 02.06.2018.pdf		Yes	Yes	Fillable Fileable
Instruction			Instructions for completing CMS 10455 508 Aug 2017.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: Automated Survey Processing Environment (ASPEN) Complaints/Incidents Tracking System (ACTS), System No. 09-70-1519

FR Citation: 71 FR 29644

Number of Respondents: 6,389

Number of Respondents for Small Entity: 6,225

Affected Public: Private Sector

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

Percentage of Respondents Reporting Electronically: 90 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	6,389	0	164	6,225
Annual IC Time Burden (Hours)	2,619	565	0	2,054
Annual IC Cost Burden (Dollars)	0	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Crosswalk	CMS 10455 crosswalk 8.8.17.pdf	02/05/2018

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