RENAL DISEASE FACILITY COST AND STATISTICAL QUESTIONNAIRE

ICR 198103-0938-007

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 198103-0938-007
Historical Active 197803-0938-016
HHS/CMS
RENAL DISEASE FACILITY COST AND STATISTICAL QUESTIONNAIRE
Reinstatement with change of a previously approved collection   No
Regular
Approved without change 03/16/1981
Retrieve Notice of Action (NOA) 03/14/1981
  Inventory as of this Action Requested Previously Approved
04/30/1981 04/30/1981
900 0 0
900 0 0
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 0 0 0 900 0
Annual Time Burden (Hours) 900 0 0 0 900 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.
03/14/1981


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