CLINICAL SOCIAL WORKERS QUESTIONNAIRE

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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
113471	CLINICAL SOCIAL WORKERS QUESTIONNAIRE		Migrated

ICR Details

OMB Control No:	ICR Reference No: 198312-0938-019
Status: Historical Inactive	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: CLINICAL SOCIAL WORKERS QUESTIONNAIRE
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Disapproved	Conclusion Date: 03/26/1984
	Date Received in OIRA: 12/27/1983
Terms of Clearance: THIS COLLECTION IS NOT APPROVED UNDER THE PROVISIONS AT 1320.4[b]1 AND 2. AS CURRENTLY DESIGNED, THE QUESTIONAIRE WILL PROVIDE ANECDOTAL INFORMATION FROM CLINICAL SOCIAL WORKERS ON PRACTICE PATTERNS, REFERRA SOURCES, OPINIONS CONCERNING MEDICARE REIMBURSEMENT POLICIES FOR MENTA HEALTH SERVICES, DEMOGRAPHIC INFORMATION, AND PERSONAL ESTIMATES OF REIMBURSEMENT FOR CLINICAL SOCIAL WORKER SERVICES. NEITHER THE RELIABILITY OF THE DATA NOR THEIR RELEVANCE TO ACHIEVING THE MAJOR GOALS OF THE EVALUATION HAS BEEN DEMONSTRATED. A LESS BURDENSOME AND POTENTIALLY MORE USEFUL APPROACH WOULD BE TO RELY UPON EXISTING BILLING DATA AND CURRENT MEDICARE CONTRACTOR SERVICES TO RETRIEVE THE DATA NECESSARY TO MEET THE STATUTORY REQUIREMENT.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date
Responses	0	0	0
Time Burden (Hours)	0	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: THE QUESTIONNAIRE WILL PROVIDE ON-LINE DATA FOR USE IN THE EVALUATION OF DIRECT REIMBURSEMENT OF CLINICAL SOCIAL WORKERS DEMONSTRATION PROJECT. IT IS NEEDED BECAUSE IMPORTANT INFORMATION ON CLINICAL SOCIALWORKERS' "INDICDENT TO RELATIONSHIPS EXTENT OF PRACTICE AS MEDICARE PROVIDERS, AND COST OF SERVICE IS NOT AVAILABLE ELSEWHERE. 2,000 CLINICAL SOCIAL WORKERS IN CALIFORNIA WILL BE ASKED TO RESPOND.

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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
CLINICAL SOCIAL WORKERS QUESTIONNAIRE

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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: 12/27/1983

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