POST CERTIFICATION REVISIT REPORT

ICR 198409-0938-004

OMB: 0938-0390

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
113634 Migrated
ICR Details
0938-0390 198409-0938-004
Historical Active
HHS/CMS
POST CERTIFICATION REVISIT REPORT
New collection (Request for a new OMB Control Number)   No
Regular
Approved without change 10/09/1984
Retrieve Notice of Action (NOA) 09/14/1984
  Inventory as of this Action Requested Previously Approved
10/31/1987 10/31/1987
53 0 0
2,500 0 0
0 0 0

THIS FORM PROVIDES A UNIFORM FORMAT DEPICTING ACTION ACCOMPLISHED AND USED AS A FOLLOW-UP TO DETECTED DEFICIENCIES REPORTED ON FORM HCFA-2567. INFORMATION FROM THIS FORM IS USED TO MAKE DECISIONS CONCERNING CERTIFICATION OF HEALTH CARE FACILITIES PARTICIPATING IN MEDICARE/MEDICAID PROGRAMS.

None
None


No

1
IC Title Form No. Form Name
POST CERTIFICATION REVISIT REPORT HCFA-2567B

  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) 2,500 0 0 0 2,500 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.
09/14/1984


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