Information Collection

Inpatient Psychiatric Facility Quality Reporting Program

IC 202349 under ICR 201905-0938-001 · 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⚠️ Notice: This information collection may be referencing outdated material.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 Screenshots (see Supporting Statement A, section 12, IPFQR web based submission screen shots_v3.pdf	Form and Instruction
CMS-10432 Notice of Participation IPFQR_NOP_FY2020.pdf	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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10432	IPF Screenshots (see Supporting Statement A, section 12,under the list of Information Collection Instruments and Instruction/Guidance Documents)	IPFQR web based submission screen shots_v3.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10432	Notice of Participation	IPFQR_NOP_FY2020.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,679

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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	13,517,629	-193,113	13,710,742
Annual IC Time Burden (Hours)	3,381,086	-50,067	3,431,153
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.