Information Collection

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

IC 236196 under ICR 202208-0938-022 · OMB 0938-1210.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10455 Documentation of information of deaths related to 2 point soft wrist restaints	Form and Instruction
CMS-10455 REPORT OF A HOSPITAL DEATH ASSOCIATED WITH THE USE OF RE CMS-10455, 01.04.22.pdf	Form and Instruction
CMS-10455 REPORT OF A HOSPITAL DEATH ASSOCIATED WITH THE USE OF RE CMS-10455, 01.04.22.pdf	Form and Instruction

IC Title:

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	REPORT OF A HOSPITAL DEATH ASSOCIATED WITH THE USE OF RESTRAINT OR SECLUSION	CMS-10455, 01.04.22.pdf		Yes	Yes	Fillable Fileable

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: 658

Number of Respondents for Small Entity: 658

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
	Approved	Program Change Due to Agency Discretion	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	658	-1,898	2,556
Annual IC Time Burden (Hours)	110	-316	426
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.