DEPARTMENTAL CLINICAL LAB SURVEY REPORT FORM

ICR 198408-0938-005

OMB: 0938-0032

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
112571 Migrated
ICR Details
0938-0032 198408-0938-005
Historical Active 198211-0938-006
HHS/CMS
DEPARTMENTAL CLINICAL LAB SURVEY REPORT FORM
Reinstatement with change of a previously approved collection   No
Regular
Approved without change 09/10/1984
Retrieve Notice of Action (NOA) 08/21/1984
  Inventory as of this Action Requested Previously Approved
12/31/1985 12/31/1985
53 0 0
11,000 0 0
0 0 0

THIS SURVEY FORM IS AN INSTRUMENT USED BY THE STATE AGENCY TO RECORD DATA COLLECTED IN ORDER TO DETERMINE COMPLIANCE WITH INDIVIDUAL CONDITIONS OF PARTICIPATION AND REPORT IT TO THE FEDERAL GOVERNMENT.

None
None


No

1
IC Title Form No. Form Name
DEPARTMENTAL CLINICAL LAB SURVEY REPORT FORM HCFA-1557

  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 53 0 0 0 53 0
Annual Time Burden (Hours) 11,000 0 0 0 11,000 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.
08/21/1984


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