PSYCHIATRIC HOSPITAL SURVEY REPORT

ICR 198007-0938-003

OMB: 0938-0104

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
112902 Migrated
ICR Details
0938-0104 198007-0938-003
Historical Active
HHS/CMS
PSYCHIATRIC HOSPITAL SURVEY REPORT
New collection (Request for a new OMB Control Number)   No
Regular
Approved without change 09/24/1980
Retrieve Notice of Action (NOA) 07/25/1980
  Inventory as of this Action Requested Previously Approved
12/31/1980 12/31/1980
370 0 0
4,562 0 0
0 0 0

INFORMATION FROM THIS FORM IS USED TO DETERMINE WHETHER A PSYCHIATRIC HOSPITAL MEETS THE REQUIREMENTS FOR PARTICIPATION IN THE MEDICARE PROGRAM. THE INFORMATION IS COLLECTED BY STATE AGENCIES. THE INFORMATION FROM THIS FORM IS ALSO USED TO PRODUCE REPORTS ON PROGRAM ACTIVITIES AND TO EVALUATE THE PERFORMANCE OF STATE AGENCIES.

None
None


No

1
IC Title Form No. Form Name
PSYCHIATRIC HOSPITAL SURVEY REPORT HCFA-1537A

  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 370 0 0 0 370 0
Annual Time Burden (Hours) 4,562 0 0 0 4,562 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.
07/25/1980


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