MEDICARE/MEDICAID - LONG TERM CARE SURVEY REPORT FORMS

ICR 198601-0938-001

OMB: 0938-0400

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
113655 Migrated
ICR Details
0938-0400 198601-0938-001
Historical Active 198412-0938-002
HHS/CMS
MEDICARE/MEDICAID - LONG TERM CARE SURVEY REPORT FORMS
Revision of a currently approved collection   No
Regular
Approved without change 02/13/1986
Retrieve Notice of Action (NOA) 01/13/1986
  Inventory as of this Action Requested Previously Approved
08/31/1987 08/31/1987 03/31/1986
16,500 0 1,500
46,175 0 7,125
0 0 0

THE LONG TER CARE SURVEY REPORT FORMS WILL BE USED BY STATE AGENCY SURVEYORS TO RECORD THE RESULTS OF THEIR SURVEYS OF ICFS AND SNFS. THESE FORMS ARE DESIGNED TO FOCUS REVIEW ON THE OUTCOMES OF PATIENT CARE RATHER THAN O THE STRUCTURAL AND PROCEDURAL REQUIREMENTS EMPHASIZED ON TRADITIONAL SURVEYS.

None
None


No

1
IC Title Form No. Form Name
MEDICARE/MEDICAID - LONG TERM CARE SURVEY REPORT FORMS HCFA-519, THRU, HCFA-525

  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 16,500 1,500 0 15,000 0 0
Annual Time Burden (Hours) 46,175 7,125 0 39,050 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
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.
01/13/1986


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