Information Collection

Submission of Hospice Quality Reporting Program Quality Data using a web based data entry form

IC 203679 under ICR 202409-0938-004 · OMB 0938-1153.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10390 Submission of Hospice Quality Reporting Program Quality Data using a web based data entry form	Form and Instruction
CMS-10390 Hospice Item Set - Descriptions HOPE v1.00_All Item_508c.pdf	Form and Instruction
CMS-10390 Hospice Item Set - Admissions HOPE v1.00_Admission_508c.pdf	Form and Instruction
CMS-10390 Hospice Item Set - Discharge HOPE v1.00_Discharge_508c.pdf	Form and Instruction
CMS-10390 HOPE Update Visit HOPE v1.00_HOPE Update Visit_508c.pdf	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10390	Hospice Item Set - Descriptions	HOPE v1.00_All Item_508c.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10390	Hospice Item Set - Admissions	HOPE v1.00_Admission_508c.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10390	Hospice Item Set - Discharge	HOPE v1.00_Discharge_508c.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10390	HOPE Update Visit	HOPE v1.00_HOPE Update Visit_508c.pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: Hospice Item Set (HIS) System

FR Citation: 79 FR 19341

Number of Respondents: 5,640

Number of Respondents for Small Entity: 4,850

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	Previously Approved
Annual Number of Responses for this IC	2,763,850	2,763,850
Annual IC Time Burden (Hours)	1,323,883	1,323,883
Annual IC Cost Burden (Dollars)	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.