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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:
Modified
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 Form
DACAForm2016_121714.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10210
Hospital VPB Review and Corrections Form
HVBP_RevwCrrctnsReqForm_032013.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10210
Extraordinary Circumstances Form
Extraordinary Circumstances Form - Final 03.03.2015-fF.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10210
Inpatient Withholding Data form
IP-WithldngReqFormPR_Jul2015.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10210
IQR Measure Exception Form
IQR_MeasureExceptionForm_02.23.2015-FF.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10210
IQR Notice of Participation Form
IQR_NOP_AgreementText_022615.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10210
IQR Reconsideration Request Form
IQR_ReconReqForm_V4_022615,0.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10210
CAUTI Validation Template
VAL_FY17_CAUTI_Validation Template_201410.xlsx
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10210
CDI Validation Template
VAL_FY17_CDI_Validation Template_201410.xlsx
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10210
CLABSI Validation Template
VAL_FY17_CLABSI_Validation Template_201410.xlsx
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10210
MRSA Validation Template
VAL_FY17_MRSA_Validation Template_201410.xlsx
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10210
Validation Review for Reconsideration Request
ValidnReviewReq_062212.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10210
VBP Appeal Request Form
VBP Appeal Request Form_03_2013.doc
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 %
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)
7,968,928
0
1,918,928
0
0
6,050,000
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
HIQR Forms Crosswalk
HIQR Information Collection Forms Crosswalk_3.10.2015_NO4.6.2015_CLEAN.docx
06/04/2015
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.