Information Collection

Inpatient Psychiatric Facility Quality Reporting Program

IC 202349 under ICR 202505-0938-004 · OMB 0938-1171.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1171 can be found here:

2026-05-28 - Revision of a currently approved collection

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10432 Inpatient Psychiatric Facility Quality Reporting Program	Form and Instruction
Form CMS-10432 IPFQR Program Data Entry Screen Shots Inpatient Psychiatric Facility Quality Reporting Program	Form and Instruction
Form CMS-10432 IPFQR_PIX Survey Inpatient Psychiatric Facility Quality Reporting Program	Form and Instruction
Form CMS-10432 Data Accuracy and Completeness Acknowledgement (DACA) Inpatient Psychiatric Facility Quality Reporting Program	Form and Instruction
CMS-10432 IPFQR Program Data Entry Screen Shots IPFQR Program Data Entry Screen Shots_.pdf	Form and Instruction
CMS-10432 IPFQR Program Data Entry Screen Shots IPFQR Program Data Entry Screen Shots_.pdf	Form and Instruction
CMS-10432 IPFQR_PIX Survey IPFQR_PIX Survey (final-2-25-25).pdf	Form and Instruction
CMS-10432 IPFQR_PIX Survey IPFQR_PIX Survey (final-2-25-25).pdf	Form and Instruction
CMS-10432 Data Accuracy and Completeness Acknowledgement (DACA) IPF DACA_clean submission_5.14.25.docx	Form and Instruction
CMS-10432 Data Accuracy and Completeness Acknowledgement (DACA) IPF DACA_clean submission_5.14.25.docx	Form and Instruction
IPFQR Program Data Entry Screen Shots_ redline.pdf Track Change - IPFQR Program Data Entry Screen Shots	IC Document
IPFQR Program Data Entry Screen Shots_ redline.pdf Track Change - IPFQR Program Data Entry Screen Shots	IC Document
IPF DACA_redline submission_.pdf Track Chage - Data Accuracy and Completeness Acknowledgement (DACA)	IC Document
IPF DACA_redline submission_.pdf Track Chage - Data Accuracy and Completeness Acknowledgement (DACA)	IC Document

Information Collection (IC) Details

View Information Collection (IC)

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:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10432	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10432	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10432	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

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: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	10,820,880	-2,017,344	12,838,224
Annual IC Time Burden (Hours)	2,645,051	-67,214	2,712,265
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Track Change - IPFQR Program Data Entry Screen Shots		05/19/2025
Track Chage - Data Accuracy and Completeness Acknowledgement (DACA)		05/21/2025

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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