Submission of Hospice Quality Reporting Program Quality Data using a web based data entry form

Hospice Quality Reporting Program

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1153 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10390 Submission of Hospice Quality Reporting Program Quality Data using a web based data entry form Form and Instruction
CMS-10390 Hospice Item Set - Descriptions HQRP Hospice Item Set- Item Descriptions_final.pdf Form and Instruction
CMS-10390 Hospice Item Set - Admissions HQRP Hospice Item Set Admission_final.pdf Form and Instruction
CMS-10390 Hospice Item Set - Discharge HQRP Hospice Item Set Discharge_final.pdf Form and Instruction
Hospice PRA Burden Estimate 08 23 13.docx Burden Calculation Worksheet IC Document
Changes to Hospice Item Set 12 4 13.pdf Crosswalk IC Document

Information Collection (IC) Details

IC Title:	Submission of Hospice Quality Reporting Program Quality Data using a web based data entry form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

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-10390	Hospice Item Set - Discharge	HQRP Hospice Item Set Discharge_final.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10390	Hospice Item Set - Descriptions	HQRP Hospice Item Set- Item Descriptions_final.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10390	Hospice Item Set - Admissions	HQRP Hospice Item Set Admission_final.pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 3,742	Number of Respondents for Small Entity: 3,555

Affected Public: Private Sector	Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	3,742	110	3,632
Annual IC Time Burden (Hours)	525,827	-131,565	657,392
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Burden Calculation Worksheet	Hospice PRA Burden Estimate 08 23 13.docx	03/25/2014
Crosswalk	Changes to Hospice Item Set 12 4 13.pdf	03/25/2014

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