Information Collection

Inpatient Psychiatric Facility Quality Reporting Program

IC 202349 under ICR 202604-0938-008 · OMB 0938-1171.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10432 Data Accuracy and Completeness Acknowledgement (DACA) Inpatient Psychiatric Facility Quality Reporting Program	Form and Instruction
Form CMS-10432 IPFQR Data Entry Screen Shots Inpatient Psychiatric Facility Quality Reporting Program	Form and Instruction
Form CMS-10432 Psychiatric Inpatient Experience (PIX) Survey Inpatient Psychiatric Facility Quality Reporting Program	Form and Instruction
CMS-10432 Data Accuracy and Completeness Acknowledgement (DACA) CMS-10432_1_IPFQR_PRA_CY 2027_DACA_clean_01282026.docx	Form and Instruction
CMS-10432 IPFQR Data Entry Screen Shots CMS-10432_2-7_IPFQR Data Entry Screen Shots_clean.docx	Form and Instruction
CMS-10432 Psychiatric Inpatient Experience (PIX) Survey CMS-10432_8_IPFQR_PIX_CMS_English_March 2025_01282026.pdf	Form and Instruction
CMS-10432_1_IPFQR_PRA_CY 2027_DACA_redlined_01282026.docx Track Chage - Data Accuracy and Completeness Acknowledgement (DACA)	IC Document
CMS-10432_2-7_IPFQR Data Entry Screen Shots_tracked changes.docx Track Change - IPFQR Data Entry Screen Shots	IC Document

IC Title:

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

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: 1,564

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 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	8,952,336	-1,868,544	10,820,880
Annual IC Time Burden (Hours)	2,179,121	-465,930	2,645,051
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Track Chage - Data Accuracy and Completeness Acknowledgement (DACA)		05/18/2026
Track Change - IPFQR Data Entry Screen Shots		05/18/2026

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

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