CONTRACTORS INFORMATION COLLECTIONS - STATE SURVEY AGENCY CORRECTION OF DEFICIENCY FORMS

ICR 198112-0938-012

OMB: 0938-0044

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
0938-0044 198112-0938-012
Historical Active 198106-0938-007
HHS/CMS
CONTRACTORS INFORMATION COLLECTIONS - STATE SURVEY AGENCY CORRECTION OF DEFICIENCY FORMS
Revision of a currently approved collection   No
Regular
Approved without change 12/16/1981
Retrieve Notice of Action (NOA) 12/04/1981
  Inventory as of this Action Requested Previously Approved
04/30/1983 04/30/1983 08/31/1983
17,500 0 17,500
26,250 0 1,120
0 0 0

THESE FORMS ARE USED BY SOME STATE SURVEY AGENCIES TO ALLOW FACILITIES PARTICIPATING IN MEDICARE/MEDICAID TO REPORT ON THEIR PROGRESS IN CORRECTING DEFICIENCIES FOUND DURING A PRIOR SURVEY. THE FORMS COLLECT INFORMATION WHICH STATE SURVEY AGENCIES WOULD HAVE RECORDED DURING AN ON-SITE FOLLOW-UP VISIT ON HCFA-2567B AND HCFA-2567E FORMS.

None
None


No

1
IC Title Form No. Form Name
CONTRACTORS INFORMATION COLLECTIONS - STATE SURVEY AGENCY CORRECTION OF DEFICIENCY FORMS HCFA-9034, 2567B

  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 17,500 17,500 0 0 0 0
Annual Time Burden (Hours) 26,250 1,120 0 0 25,130 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.
12/04/1981


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