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Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
Quality Measures and Procedures for Hospital Reporting of Quality Data
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Unchanged
Obligation to Respond:
Required to Obtain or Retain Benefits
CFR Citation:
Information Collection Instruments:
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 Acknowledgemenmt
DACAForm2015_Final.doc
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10210
HVBP Review and Corrections Form
VBP Review and Corrections Request Form_03_2013.doc
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10210
HVBP Appeal Request Form
VBP Appeal Request Form_03_2013.doc
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10210
Validation Template CAUTI
Validation TemplateCatheter-Associated Urinary Tract Infection (CAUTI).xlsx
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10210
Validation Template MRSA
Validation Template for MRSA.xlsx
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10210
Validation Template CLABSI
Validation Template for CLABSI_BloodCultureTemplate.xlsx
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10210
Validation Template CDI
Validation Template for CDI.xlsx
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10210
Request for Withholding Data from Public Reporting
Request for withholding.doc
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10210
Reconsideration Request Form electronic
ReconsiderationRequest_English.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10210
Extroadinary Circumstances Disaster Waiver
ExtraordinaryCircumstance_Disaster Waiver.docx
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10210
Healthcare Associated Infection Exception Form
HealthcareAssociatedInfection_ExceptionForm.doc
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10210
HVBP Appeal Request Form Screen Shot
HVBP Appeal Request Form_03_2013.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10210
HVBP Review and Correction Rquest Form Screen Shot
HVBP Review and Corrections Request Form_03_2013.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10210
HIQR Notice of Participation Form
Notice of Participation.docx
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10210
Reconsideration Request Form
ReconsiderationRequest_English.docx
Yes
Yes
Fillable Fileable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Public Health Monitoring
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
4,400
Number of Respondents for Small Entity:
0
Affected Public:
Private Sector
Private Sector:
Businesses or other for-profits
Percentage of Respondents Reporting Electronically:
100 %
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
17,600
0
0
0
0
17,600
Annual IC Time Burden (Hours)
6,050,000
0
-700,000
0
0
6,750,000
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.