Documentation of information of deaths related to 2 point soft wrist restaints

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⚠️ Notice: This information collection may be referencing outdated material.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

no available documents/forms check other ICs listed under this ICR

Information Collection (IC) Details

IC Title:	Documentation of information of deaths related to 2 point soft wrist restaints	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

Line of Business: Health

Subfunction: Health Care Services

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

Number of Respondents: 2,556	Number of Respondents for Small Entity: 1,917

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

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	2,556	2,556
Annual IC Time Burden (Hours)	426	426
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.