RENAL DISEASE FACILITY COST AND STATISTICAL QUESTIONNAIRE

ICR 197803-0938-016

OMB: 0938-0048

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
ICR Details
0938-0048 197803-0938-016
Historical Active 197612-0938-001
HHS/CMS
RENAL DISEASE FACILITY COST AND STATISTICAL 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
01/31/1981 01/31/1981 01/31/1981
900 0 600
900 0 600
0 0 0

THESE FORMS ARE USED BY ALL RENAL DISEASE SUPPLIERS TO REPORT COST DATA AND UTILIZATION AND STAFFING PATTERNS TO THE PART-A INTERMEDIARY. THEY ARE ALSO USED FOR INPUTTING COST DATA INTO THE DIALYSIS COST ANALYSIS PROGRAM AND ARE USED BY THE CRD REIMBURSEMENT SCREENS.

None
None


No

1
IC Title Form No. Form Name
RENAL DISEASE FACILITY COST AND STATISTICAL QUESTIONNAIRE SSA 9734

  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 900 600 0 0 300 0
Annual Time Burden (Hours) 900 600 0 0 300 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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