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 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

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) 7,968,928 0 1,918,928 0 0 6,050,000
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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.