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

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

Documents and Forms

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

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: Modified

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	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 %

	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

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.