HOSPITAL INSTITUTIONAL PLANNING QUESTIONNAIRE

ICR 197803-0938-009

OMB: 0938-0054

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
IC ID
Document
Title
Status
166108 Migrated
ICR Details
0938-0054 197803-0938-009
Historical Active 197601-0938-001
HHS/CMS
HOSPITAL INSTITUTIONAL PLANNING QUESTIONNAIRE
No material or nonsubstantive change to a currently approved collection   No
Emergency 03/29/1978
Approved with change 03/29/1978
Retrieve Notice of Action (NOA) 03/29/1978
  Inventory as of this Action Requested Previously Approved
02/28/1981 02/28/1981 02/28/1981
6,650 0 2,000
3,325 0 1,000
0 0 0

THIS FORM IS USED TO ASSESS WHETHER A HOSPITAL WHICH IS ACCREDITED BY JCAH OR AOA HAS AN OVERALL PLAN AND BUDGET IN EFFECT WHICH MEETS MEDICARE CERTIFICATION REQUIREMENTS.

None
None


No

1
IC Title Form No. Form Name
HOSPITAL INSTITUTIONAL PLANNING QUESTIONNAIRE SSA-3213, HCFA-3213

  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 6,650 2,000 0 0 4,650 0
Annual Time Burden (Hours) 3,325 1,000 0 0 2,325 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected

  No

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
03/29/1978


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