Information Collection

Quality Measures and Procedures for Hospital Reporting of Quality Data

IC 204350 under ICR 201511-0938-001 · 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⚠️ Notice: This information collection may be referencing outdated material.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 CMS-10210 Quality Measures and Procedures for Hospital Reporting of Quality Data Form and Instruction
CMS-10210 Data Accuracy and Completeness Form DACAForm2016_121714.pdf Form and Instruction
CMS-10210 Hospital VPB Review and Corrections Form HVBP_RevwCrrctnsReqForm_032013.pdf Form and Instruction
CMS-10210 Extraordinary Circumstances Form Extraordinary Circumstances Form - Final 03.03.2015-fF.pdf Form and Instruction
CMS-10210 Inpatient Withholding Data form IP-WithldngReqFormPR_Jul2015.pdf Form and Instruction
CMS-10210 IQR Measure Exception Form IQR_MeasureExceptionForm_02.23.2015-FF.pdf Form and Instruction
CMS-10210 IQR Notice of Participation Form IQR_NOP_AgreementText_022615.pdf Form and Instruction
CMS-10210 IQR Reconsideration Request Form IQR_ReconReqForm_V4_022615,0.pdf Form and Instruction
CMS-10210 CAUTI Validation Template VAL_FY17_CAUTI_Validation Template_201410.xlsx Form and Instruction
CMS-10210 CDI Validation Template VAL_FY17_CDI_Validation Template_201410.xlsx Form and Instruction
CMS-10210 CLABSI Validation Template VAL_FY17_CLABSI_Validation Template_201410.xlsx Form and Instruction
CMS-10210 MRSA Validation Template VAL_FY17_MRSA_Validation Template_201410.xlsx Form and Instruction
CMS-10210 Validation Review for Reconsideration Request ValidnReviewReq_062212.pdf Form and Instruction
CMS-10210 VBP Appeal Request Form VBP Appeal Request Form_03_2013.doc Form and Instruction
HIQR Information Collection Forms Crosswalk_7.30.2015_CLEAN.docx Crosswalk IC Document

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: Modified

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 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 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	17,600	0	17,600
Annual IC Time Burden (Hours)	7,951,695	1,901,695	6,050,000
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Crosswalk	HIQR Information Collection Forms Crosswalk_7.30.2015_CLEAN.docx	11/02/2015

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