Inpatient Psychiatric Facility Quality Reporting Program

Inpatient Psychiatric Facility Quality Reporting Program (CMS-10432)

Documents and Forms

Document Name Document Type
Form CMS-10432 Inpatient Psychiatric Facility Quality Reporting Program Form
CMS-10432 PIX Survey IPFQR_PIX Survey.pdf Form
CMS-10432 IPFQR Program Data Entry Screen Shots IPFQR Program Data Entry Screen Shots.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Inpatient Psychiatric Facility Quality Reporting Program	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10432	PIX Survey	IPFQR_PIX Survey.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10432	IPFQR Program Data Entry Screen Shots	IPFQR Program Data Entry Screen Shots.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: Medicare Beneficiary Database (09-70-0536)	FR Citation: 71 FR 70396

Number of Respondents: 1,596	Number of Respondents for Small Entity: 0

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

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Previously Approved
Annual Number of Responses for this IC	12,838,224	12,838,224
Annual IC Time Burden (Hours)	2,712,265	2,712,265
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.