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 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 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
IPF DACA_redline submission_.pdf Track Chage - Data Accuracy and Completeness Acknowledgement (DACA) IC Document

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10432	IPFQR Program Data Entry Screen Shots	IPFQR Program Data Entry Screen Shots_.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10432	IPFQR_PIX Survey	IPFQR_PIX Survey (final-2-25-25).pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10432	Data Accuracy and Completeness Acknowledgement (DACA)	IPF DACA_clean submission_5.14.25.docx	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: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	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

Title	Document	Date Uploaded
Track Change - IPFQR Program Data Entry Screen Shots	IPFQR Program Data Entry Screen Shots_ redline.pdf	05/19/2025
Track Chage - Data Accuracy and Completeness Acknowledgement (DACA)	IPF DACA_redline submission_.pdf	05/21/2025

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