View Information Collection (IC)
View Information Collection (IC)

View Information Collection (IC)

Quality Measures and Procedures for Hospital Reporting of Quality Data
 
No Modified
 
Required to Obtain or Retain Benefits
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-10210 Data Accuracy and Completeness Form IQR_DACA__PY 2019_vFinal_3.3.2017(508).pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10210 Hospital VPB Review and Corrections Form HVBP_Review_and_Corrections_Request_Form_Final_3.3.2017.(508).pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10210 Extraordinary Circumstances Form HQR ECE Request Form Final 3.3.2017(508ff).pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10210 Inpatient Withholding Data form PR_Oct2017_IP HC Withholding Request_Form_Final 3-3-2017.(508).pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10210 IQR Measure Exception Form IPPS_MeasureExceptionForm_3.3.2017 ff.(508).pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10210 IQR Notice of Participation Form IQR NOP Text 3.3.2017.(508).pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10210 IQR Reconsideration Request Form IQR_Form_ReconsiderationRequest_3.6.2017_Final(508).pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10210 CAUTI Validation Template FY20_CAUTI_ValidationTemplate_20170303.xlsx Yes Yes Fillable Fileable
Form and Instruction CMS-10210 CDI Validation Template FY20_CDI_ValidationTemplate_20170303.xlsx Yes Yes Fillable Fileable
Form and Instruction CMS-10210 CLABSI Validation Template 1Q18-2Q18 FY20_CLABSI_ValidationTemplate_1Q18-2Q18_20170303.xlsx Yes Yes Fillable Fileable
Form and Instruction CMS-10210 MRSA Validation Template FY20_MRSA_ValidationTemplate_20170303.xlsx Yes Yes Fillable Fileable
Form and Instruction CMS-10210 Validation Review for Reconsideration Request IQR_Form_ValidnReviewReq_3.6.2017_Final.( 508 )ff.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10210 VBP Appeal Request Form HVBP Appeal Request Form Final 3.6.2017.(508)ff.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10210 HVBP CMS Independent Review Form HVBP CMS Independent Review Form_3.6.2017_Final.(508)ff.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10210 CLABSI Validation Template 3Q17-4Q17 FY20_CLABSI_ValidationTemplate_3Q17-4Q17_201703030.xlsx Yes Yes Fillable Fileable
Form and Instruction CMS-10210 Validation Educational Review Form VAL_IQR_EducReviewForm_3.3.2017.pdf Yes Yes Fillable Fileable

Health Public Health Monitoring

 

4,400 0
   
Private Sector Businesses or other for-profits
 
   100 %

  Requested Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 17,600 0 0 0 0 17,600
Annual IC Time Burden (Hours) 3,649,548 0 0 -31,475 0 3,681,023
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Summary of HIQR Information Collection Forms: Updates for the 2017 03 07 FY 2018 Summary of HIQR Information Collection Forms.docx 05/08/2017
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.