Submission of Form

Report of a Hospital Dealth Associated with Restraint or Seclusion (CMS-10455)

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Document Name Document Type
Form CMS-10455 Submission of Form Form and Instruction
CMS-10455 Screenshots of Electronic Submission CMS 10455 Screenshots of the Electronic Submission Process.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Submission of Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 482 Section 13

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10455	Screenshots of Electronic Submission	CMS 10455 Screenshots of the Electronic Submission Process.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: Automated Survey Prcoessing Environment (ASPEN)	FR Citation: 71 FR 29644

Number of Respondents: 1,981	Number of Respondents for Small Entity: 1,486

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

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,981	1,981
Annual IC Time Burden (Hours)	491	491
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.