OMB control number
Report of a Hospital Dealth Associated with Restraint or Seclusion (CMS-10455)
OMB 0938-1210 · HHS/CMS.
OMB 0938-1210
The CMS 10455 Report of a Hospital Death in Restraint or Seclusion form is utilized for the purpose of determining cases that warrant on-site investigation to determine the hospital’s compliance with the Medicare Condition of Participation (CoP) for patient’s rights. Based on information gathered from CMS Regional Offices (ROs), the current collection tool associated with this package did not provide the needed information to thoroughly evaluate whether the case warrants an on-site investigation. The ROs provided feedback for data needed on the CMS 10455 form to evaluate whether the case warrants an on-site investigation. The collection tool was revised based on the ROs need for additional information to assess for compliance with CoPs as well as the health and safety of patients requiring the use of restraint and/or seclusion.
The latest form for Report of a Hospital Dealth Associated with Restraint or Seclusion (CMS-10455) expires 2022-07-31 and is listed under ICR 201905-0938-011.
Latest Forms, Documents, and Supporting Material
| Document | Type |
|---|---|
 Form CMS-10455 Documentation of information of deaths related to 2 point soft wrist restaints | Form and Instruction |
| Form CMS-10455 Form completetion | Form and Instruction |
| Form CMS-10455 Training | Form and Instruction |
 CMS-10455 Supporting Statement. 08.12.22.docx | Supporting Statement A |
 Entering information into medical record |
Information collection |
| Documentation of information of deaths related to 2 point soft wrist restaints |
Form and Instruction |
| Form completetion |
Form and Instruction |
| Training |
Form and Instruction |
All Historical Document Collections
| Reference | Filing | Received | Concluded | Action |
|---|---|---|---|---|
| 202208-0938-022 | Reinstatement with change of a previously approved collection | 2022-08-25 | Approved with change | |
| 201905-0938-011 | Revision of a currently approved collection | 2019-05-30 | Approved without change | |
| 201802-0938-002 | Revision of a currently approved collection | 2018-02-08 | Approved with change | |
| 201608-0938-015 | Revision of a currently approved collection | 2016-08-25 | Approved with change | |
| 201301-0938-009 | New collection (Request for a new OMB Control Number) | 2013-01-31 | Approved without change |
OMB Details
Training
Federal Enterprise Architecture: Health - Health Care Services
| Form | Name | Electronic access | Type |
|---|---|---|---|
| Form CMS-10455 | Health Death Report Form | Fillable Fileable | Form and instruction |
Review document collections for all forms, instructions, and supporting documents - including paper/printable forms.