RECORD OF STATE AND LOCAL ACTION UNDER SECTION 1122 OF THE SOCIAL SECURITY ACT

ICR 198312-0915-004

OMB: 0915-0055

Federal Form Document

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ICR Details
0915-0055 198312-0915-004
Historical Active 198306-0915-002
HHS/HSA
RECORD OF STATE AND LOCAL ACTION UNDER SECTION 1122 OF THE SOCIAL SECURITY ACT
Revision of a currently approved collection   No
Regular
Approved without change 02/15/1984
Retrieve Notice of Action (NOA) 12/06/1983
  Inventory as of this Action Requested Previously Approved
02/28/1985 02/28/1985 12/31/1983
374 0 480
187 0 192
0 0 0

FORM WILL BE USED BY THE REGIONAL HEALTH ADMINISTRATOR, ON BEHALF OF THE SECRETARY, DHHS, TO DETERMINE WHETHER FEDERAL FUNDS APPROPRIATE UNDER TITLES XVIII AND XIX OF THE SOCIAL SECURITY ACT ARE USED TO SUPPORT ONLY NECESSARY CAPITAL EXPENDITURES WHICH EXPENDITURES ARE MADE BY OR ON BEHALF OF HEALTH CARE FACILITIES.

None
None


No

1
IC Title Form No. Form Name
RECORD OF STATE AND LOCAL ACTION UNDER SECTION 1122 OF THE SOCIAL SECURITY ACT HRSA-712

  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 374 480 0 0 -106 0
Annual Time Burden (Hours) 187 192 0 0 -5 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.
12/06/1983


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