View Information Collection (IC)

View Information Collection (IC)

IC Title:	Hospital Restraint/Seclusion Death Report Worksheet	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 482 section 13

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10455	Health Death Report Form	Hospital DeathReport Form 22 jan 13 with corrections.doc		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10455	Intake	DRS screen print 08092012.docx		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10455	Screenshot	DRS screens 06142012.docx		Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: Automated Survey Processing Environment (ASPEN) Complaints/Incidents Tracking System (ACTS), System No. 09-70-1519	FR Citation: 71 FR 29644

Number of Respondents: 4,900	Number of Respondents for Small Entity: 4,900

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 90 %

	Approved	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	24,500	0	24,500	0	0	0
Annual IC Time Burden (Hours)	8,085	0	8,085	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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