CMS-10210 Population and Sampling

Hospital Inpatient Quality Reporting Program
Population and Sampling
Please Note: A data collection tool available within the Hospital Quality Reporting system via
the Hospital Quality Reporting Secure Portal allows hospitals to complete and submit their
population and sampling data. This document is a representation of the text contained in the
population and sampling data form and is for reference purposes only.
IQR – SEPSIS
Severe Sepsis and Septic Shock
Sampling Frequency (Drop Down)
• Monthly
• Quarterly
• Not Sampled
• N/A submission not required
Population
All fields must be filled in; if you have no data for a particular item you must put in “0.”

Medicare

0

Non-Medicare
Total

Total

0

0

0

0
0

Sampling
All fields must be filled in; if you have no data for a particular item you must put in “0.”

Medicare

0

Non-Medicare
Total
Cancel

January 2025

Total

0

0
Save & Return

0

0
0

Hospital Inpatient Quality Reporting Program
Population and Sampling
PRA Disclosure Statement: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection
of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 09381022 (Expires XX/XX/XXXX). The time required to complete this information collection is estimated to average 10 minutes per
response, including the time to review instructions, search existing data resources, gather the data needed, and complete and
review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for
improving this form, please write to CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05,
Baltimore, MD 21244-1850. ****CMS Disclosure**** Please do not send applications, claims, payments, medical records or
any documents containing sensitive information to the PRA Reports Clearance Office. Please note that any
correspondence not pertaining to the information collection burden approved under the associated OMB control number
listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to
submit your documents, please contact the Inpatient Value, Incentives, and Quality Reporting Outreach and Education
Support Contractor at (844) 472-4477.

January 2025