Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Documentation of information of deaths related to 2 point soft wrist restaints Modified 658 110 0 Form and Instruction CMS-10455 REPORT OF A HOSPITAL DEATH ASSOCIATED WITH THE USE OF RESTRAINT OR SECLUSION
Entering information into medical record New 3975 316 0
Form completetion Modified 3137 784 0 Form and Instruction CMS-10455 Screenshots of Electronic Submission
Training Removed 0 0 0 Form and Instruction CMS-10455 Health Death Report Form
Instruction
Total burden requested under this ICR: 7770 1210 0  
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