Information Collection

Quality Measures and Procedures for Hospital Reporting of Quality Data

IC 203642 under ICR 201208-0938-001 · OMB 0938-1022.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1022 can be found here:

Documents and Forms

Document Name Document Type
Form 10210 Quality Measures and Procedures for Hospital Reporting of Quality Data Form
10210 Data Accuracy Form DACAForm2015_Final.doc Form
10210 Notice of Participation Notice of Participation.docx Form and Instruction
10210 Data Validation Appeal Form HospQuarterlyValidAppeal_Part1.doc Form and Instruction
10210 Extraordinary Circumstances/Waiver Request Form ExtraordinaryCircumstance.docx Form and Instruction
10210 Healthcare Associated Infection Exception Form HAI Exception.docx Form
10210 Reconsideration Request ReconsiderationRequest.docx Form and Instruction
10210 Validation Review for Reconsideration Request Recon Request_Part 2.doc Form and Instruction
10210 Inpatient Hospital Compare INPT_Apr2012_withholding_March[1].pdf Form and Instruction

Information Collection (IC) Details

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: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	10210	Data Accuracy Form	DACAForm2015_Final.doc	Yes	Yes	Fillable Fileable
Form and Instruction	10210	Notice of Participation	Notice of Participation.docx	Yes	Yes	Fillable Fileable
Form and Instruction	10210	Data Validation Appeal Form	HospQuarterlyValidAppeal_Part1.doc	Yes	Yes	Fillable Fileable
Form and Instruction	10210	Extraordinary Circumstances/Waiver Request Form	ExtraordinaryCircumstance.docx	Yes	Yes	Fillable Fileable
Form	10210	Healthcare Associated Infection Exception Form	HAI Exception.docx	Yes	Yes	Fillable Fileable
Form and Instruction	10210	Reconsideration Request	ReconsiderationRequest.docx	Yes	Yes	Fillable Fileable
Form and Instruction	10210	Validation Review for Reconsideration Request	Recon Request_Part 2.doc	Yes	Yes	Fillable Fileable
Form and Instruction	10210	Inpatient Hospital Compare	INPT_Apr2012_withholding_March[1].pdf	Yes	Yes	Paper Only

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	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	17,600	17,600
Annual IC Time Burden (Hours)	6,750,000	6,750,000
Annual IC Cost Burden (Dollars)	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.