END-STAGE RENAL DISEASE FACILITY SURVEY REPORT

ICR 197902-0938-001

OMB: 0938-0085

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
112821 Migrated
ICR Details
0938-0085 197902-0938-001
Historical Active
HHS/CMS
END-STAGE RENAL DISEASE FACILITY SURVEY REPORT
New collection (Request for a new OMB Control Number)   No
Regular
Approved without change 03/13/1979
Retrieve Notice of Action (NOA) 02/08/1979
  Inventory as of this Action Requested Previously Approved
12/31/1980 12/31/1980
1,000 0 0
12,000 0 0
0 0 0

THIS FORM IS COMPLETED BY THE MEDICARE/MEDICAID STATE SURVEY AGENCY TO DETERMINE A FACILITY'S COMPLIANCE WITH THE ESRD CONDITIONS OF COVERAGE. THE INFORMATION ON THE FORM IS OBTAINED THROUGH AN AN ONSITE SURVEY.

None
None


No

1
IC Title Form No. Form Name
END-STAGE RENAL DISEASE FACILITY SURVEY REPORT HCFA-3427

  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 1,000 0 0 0 1,000 0
Annual Time Burden (Hours) 12,000 0 0 0 12,000 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.
02/08/1979


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