Information Collection

Quality Measures and Procedures for Hospital Reporting of Quality Data

IC 204350 under ICR 201708-0938-009 · 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⚠️ Notice: This information collection may be referencing outdated material.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 IQR_DACA__PY 2019_vFinal_3.3.2017(508).pdf Form and Instruction
CMS-10210 Hospital VPB Review and Corrections Form HVBP_Review_and_Corrections_Request_Form_Final_3.3.2017.(508).pdf Form and Instruction
CMS-10210 Extraordinary Circumstances Form HQR ECE Request Form Final 3.3.2017(508ff).pdf Form and Instruction
CMS-10210 Inpatient Withholding Data form PR_Oct2017_IP HC Withholding Request_Form_Final 3-1-2017rev 5-5-2017.(508).pdf Form and Instruction
CMS-10210 IQR Measure Exception Form IPPS_MeasureExceptionForm_3.3.2017 ff.(508).pdf Form and Instruction
CMS-10210 IQR Notice of Participation Form IQR NOP Text 3.3.2017.(508).pdf Form and Instruction
CMS-10210 IQR Reconsideration Request Form IQR_Form_ReconsiderationRequest_3.6.2017_Final(508).pdf Form and Instruction
CMS-10210 CAUTI Validation Template FY20_CAUTI_ValidationTemplate_20170303.xlsx Form and Instruction
CMS-10210 CDI Validation Template FY20_CDI_ValidationTemplate_20170303.xlsx Form and Instruction
CMS-10210 CLABSI Validation Template 1Q18-2Q18 FY20_CLABSI_ValidationTemplate_1Q18-2Q18_20170303.xlsx Form and Instruction
CMS-10210 MRSA Validation Template FY20_MRSA_ValidationTemplate_20170303.xlsx Form and Instruction
CMS-10210 Validation Review for Reconsideration Request IQR_Form_ValidnReviewReq_3.6.2017_Final.( 508 )ff.pdf Form and Instruction
CMS-10210 VBP Appeal Request Form HVBP Appeal Request Form Final 3.6.2017.(508)ff.pdf Form and Instruction
CMS-10210 HVBP CMS Independent Review Form HVBP CMS Independent Review Form_3.6.2017_Final.(508)ff.pdf Form and Instruction
CMS-10210 CLABSI Validation Template 3Q17-4Q17 FY20_CLABSI_ValidationTemplate_3Q17-4Q17_201703030.xlsx Form and Instruction
CMS-10210 Validation Educational Review Form VAL_IQR_EducReviewForm_3.3.2017.pdf Form and Instruction
2017 08 04 FY 2018 Final Rule Summary of HIQR Information Collection Forms.docx Summary of HIQR Information Collection Forms: Updates for the 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	CLABSI Validation Template 1Q18-2Q18	FY20_CLABSI_ValidationTemplate_1Q18-2Q18_20170303.xlsx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10210	Data Accuracy and Completeness Form	IQR_DACA__PY 2019_vFinal_3.3.2017(508).pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10210	Hospital VPB Review and Corrections Form	HVBP_Review_and_Corrections_Request_Form_Final_3.3.2017.(508).pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10210	Extraordinary Circumstances Form	HQR ECE Request Form Final 3.3.2017(508ff).pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10210	MRSA Validation Template	FY20_MRSA_ValidationTemplate_20170303.xlsx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10210	Validation Review for Reconsideration Request	IQR_Form_ValidnReviewReq_3.6.2017_Final.( 508 )ff.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10210	VBP Appeal Request Form	HVBP Appeal Request Form Final 3.6.2017.(508)ff.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10210	HVBP CMS Independent Review Form	HVBP CMS Independent Review Form_3.6.2017_Final.(508)ff.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10210	CLABSI Validation Template 3Q17-4Q17	FY20_CLABSI_ValidationTemplate_3Q17-4Q17_201703030.xlsx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10210	Validation Educational Review Form	VAL_IQR_EducReviewForm_3.3.2017.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10210	Inpatient Withholding Data form	PR_Oct2017_IP HC Withholding Request_Form_Final 3-1-2017rev 5-5-2017.(508).pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10210	IQR Measure Exception Form	IPPS_MeasureExceptionForm_3.3.2017 ff.(508).pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10210	IQR Notice of Participation Form	IQR NOP Text 3.3.2017.(508).pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10210	IQR Reconsideration Request Form	IQR_Form_ReconsiderationRequest_3.6.2017_Final(508).pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10210	CAUTI Validation Template	FY20_CAUTI_ValidationTemplate_20170303.xlsx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10210	CDI Validation Template	FY20_CDI_ValidationTemplate_20170303.xlsx	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)	3,637,282	-43,741	3,681,023
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Summary of HIQR Information Collection Forms: Updates for the	2017 08 04 FY 2018 Final Rule Summary of HIQR Information Collection Forms.docx	08/18/2017

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