PRESURGICAL SCREENING PROGRAM COST BENEFIT ANALYSIS QUESTIONNAIRE

ICR 197812-0938-002

OMB: 0938-0119

Federal Form Document

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Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
ICR Details
0938-0119 197812-0938-002
Historical Active
HHS/CMS
PRESURGICAL SCREENING PROGRAM COST BENEFIT ANALYSIS QUESTIONNAIRE
New collection (Request for a new OMB Control Number)   No
Regular
Approved without change 01/03/1979
Retrieve Notice of Action (NOA) 12/15/1978
  Inventory as of this Action Requested Previously Approved
10/31/1980 10/31/1980
800 0 0
400 0 0
0 0 0

COLLECT SOCIO-ECONOMIC DATA AND HISTORICAL INFORMATION ON PATIENT'S LABOR MARKET EARNINGS PATTERN AS WELL AS INFORMATION PERTAINING TO DISABILITY AND COSTS FOR MEDICAL SERVICES INCLUDING TRAVEL. THE INFORMATION WILL BE USED IN A COST-BENEFIT ANALYSIS OF THE PROGRAM.

None
None


No

1
IC Title Form No. Form Name
PRESURGICAL SCREENING PROGRAM COST BENEFIT ANALYSIS QUESTIONNAIRE HCFA-82

  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 800 0 0 0 800 0
Annual Time Burden (Hours) 400 0 0 0 400 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.
12/15/1978


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