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Submission of Hospice Quality Reporting Program Quality Data using a web based data entry form
Hospice Quality Reporting Program (CMS-10390)
OMB: 0938-1153
IC ID: 203679
OMB.report
HHS/CMS
OMB 0938-1153
ICR 201604-0938-010
IC 203679
( )
⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1153 can be found here:
2024-09-05 - Revision of a currently approved collection
2024-07-26 - Revision of a currently approved collection
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 v2
CMS-10390 - Hospice Item Set v2 Admission.pdf
Form and Instruction
CMS-10390 Hospice Item Set - Discharge v2
CMS-10390 - Hospice Item Set v2 Discharge.pdf
Form and Instruction
CMS-10390 Exhibit A FY 2017 Hospice PRA Burden Estimate Calculation Worksheet.pdf
Burden Calculation Worksheet
IC Document
CMS-10390 - Hospice Item Set V2 Change Table.pdf
Crosswalk
IC Document
Information Collection (IC) Details
View Information Collection (IC)
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
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
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 v2
CMS-10390 - Hospice Item Set v2 Admission.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10390
Hospice Item Set - Discharge v2
CMS-10390 - Hospice Item Set v2 Discharge.pdf
Yes
Yes
Fillable Fileable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Health Care Services
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
4,259
Number of Respondents for Small Entity:
4,046
Affected Public:
Private Sector
Private Sector:
Businesses or other for-profits, Not-for-profit institutions
Percentage of Respondents Reporting Electronically:
100 %
Requested
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
4,259
0
0
517
0
3,742
Annual IC Time Burden (Hours)
686,631
0
0
160,804
0
525,827
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
Burden Calculation Worksheet
CMS-10390 Exhibit A FY 2017 Hospice PRA Burden Estimate Calculation Worksheet.pdf
04/28/2016
Crosswalk
CMS-10390 - Hospice Item Set V2 Change Table.pdf
04/28/2016
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.