HOSPITAL SURVEY REPORT FORM

ICR 198204-0938-006

OMB: 0938-0103

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
112900 Migrated
ICR Details
0938-0103 198204-0938-006
Historical Active 198112-0938-011
HHS/CMS
HOSPITAL SURVEY REPORT FORM
Reinstatement with change of a previously approved collection   No
Regular
Approved without change 05/21/1982
Retrieve Notice of Action (NOA) 04/02/1982
  Inventory as of this Action Requested Previously Approved
09/30/1982 09/30/1982
1,026 0 0
23,598 0 0
0 0 0

INFORMATION FROM THIS FORM IS USED TO DETERMINE WHETHER A HOSPITAL MEETS THE REQUIREMENTS FOR PARTICIPATION IN THE MEDICARE PROGRAM AS STATED IN 42 CFR 405.1020-1034. THE INFORMATION IS COLLECTED BY STATE AGENCIES AND USED TO PRODUCE REPORTS ON PROGRAM ACTIVITIES AND TO EVALUATE STATE AGENCY PERFORMANCE.

None
None


No

1
IC Title Form No. Form Name
HOSPITAL SURVEY REPORT FORM HCFA-1537, 1514

  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 1,026 0 0 0 1,026 0
Annual Time Burden (Hours) 23,598 0 0 0 23,598 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.
04/02/1982


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