GENERAL INTERMEDIATE CARE FACILITY SURVEY REPORT

ICR 198107-0938-014

OMB: 0938-0062

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
166119 Migrated
ICR Details
0938-0062 198107-0938-014
Historical Active 198101-0938-006
HHS/CMS
GENERAL INTERMEDIATE CARE FACILITY SURVEY REPORT
No material or nonsubstantive change to a currently approved collection   No
Emergency 07/28/1981
Approved with change 07/28/1981
Retrieve Notice of Action (NOA) 07/28/1981
  Inventory as of this Action Requested Previously Approved
02/28/1982 02/28/1982 12/31/1981
14,156 0 14,156
87,700 0 87,700
0 0 0

IN ORDER TO PARTICIPATE IN THE MEDICARE AND MEDICAID PROGRAMS, ICFS AND ICF/MR'S MUST MEET CERTAIN FEDERAL STATUTORY AND REGULATORY REQUIREMENTS. THIS INFORMATION COLLECTION IS USED TO DETERMINE IF THE FACILITY IS IN COMPLIANCE WITH ESTABLISHED STANDARDS.

None
None


No

1
IC Title Form No. Form Name
GENERAL INTERMEDIATE CARE FACILITY SURVEY REPORT HCFA-3070 &, A THRU D

  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 14,156 14,156 0 0 0 0
Annual Time Burden (Hours) 87,700 87,700 0 0 0 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.
07/28/1981


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