HOME HEALTH AGENCY REQUEST FOR CERTIFICATION PAPERWORK BURDEN ASSOCIATED WITH HOME HEALTH

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability

No forms / supporting documents in this ICR. Check IC Document Collections.

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
112498	HOME HEALTH AGENCY REQUEST FOR CERTIFICATION PAPERWORK BURDEN ASSOCIATED WITH HOME HEALTH	Form	Migrated

ICR Details

OMB Control No: 0938-0011	ICR Reference No: 198212-0938-004
Status: Historical Inactive	Previous ICR Reference No: 198204-0938-003
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: HOME HEALTH AGENCY REQUEST FOR CERTIFICATION PAPERWORK BURDEN ASSOCIATED WITH HOME HEALTH
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Disapproved and continue	Conclusion Date: 02/03/1983
	Date Received in OIRA: 12/23/1982
Terms of Clearance: AS INDICATED IN CHRISTOPHER DEMUTHS JANUARY 4, 1983, LETTER TO DALE SOPPER, ANY FORM PRESCRIBED FOR USE BY HHS AS PART OF AN INFORMATION COLLECTION MUST SHOW A CURRENT OMB NUMBER. SINCE HHS REQUIRES STATE INSPECTION AGENCIES OR OTHER PERSONS TO USE THE HCFA 1572, IT MAY ONLY BE USED IF IT REFLECTS A CURRENT OMB NUMBER. THIS CLEARANCE REQUEST IS THEREFORE NOT APPROVED SINCE IT IS INCONSISTENT WITH THE TERMS OF THE PAPERWORK REDUCTION ACT IN THAT HHS IS PROPOSING TO REVISE THE HCF 1572 BY REMOVING THE OMB NUMBER. HOWEVER, THE CURRENT COLLECTION ENTITLED HOME HEALTH AGENCY SURVEY REPORT INCLUSIVE OF THE HCFA 1572 REFLECTING THE OMB NUMBER MAY CONTINUE IN USE THROUGH APRIL 1983.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/1982	04/30/1983	12/31/1982
Responses	1,860	0	1,860
Time Burden (Hours)	15,500	0	15,500
Cost Burden (Dollars)	0	0	0

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Abstract: HCFA 1515 INITIATES CERTIFICATION PROCEDURES FOR HHAS TO PARTICIPATE IN MEDICARE/MEDICAID. THE SURVEY IS USED TO DETERMINE IF PROVIDERS INITIALLY MEET AND/OR CONTINUE TO MEET PROGRAM REQUIREMENTS FOR PARTICIPATION.

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Authorizing Statute(s): None

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:

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Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
HOME HEALTH AGENCY REQUEST FOR CERTIFICATION PAPERWORK BURDEN ASSOCIATED WITH HOME HEALTH	HCFA 1515, HCFA R-15

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Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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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:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(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;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

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.

Certification Date: 12/23/1982

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