MEDICARE - PSYCHIATRIC HOSPITAL MEDICARE SURVEY REPORT FORM

ICR 198606-0938-007

OMB: 0938-0378

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
ICR Details
0938-0378 198606-0938-007
Historical Active 198408-0938-003
HHS/CMS
MEDICARE - PSYCHIATRIC HOSPITAL MEDICARE SURVEY REPORT FORM
Revision of a currently approved collection   No
Regular
Approved without change 08/26/1986
Retrieve Notice of Action (NOA) 06/27/1986
ALL FUTURE REQUESTS FOR CLEARANCE OF THE PSYCHIATRIC HOSPITAL MEDICARE SURVEY REPORT FORM MUST INCLUDE A COPY OF THE SURVEYOR INTERPRETIVE GUIDELINES THAT HCFA TRANSMITS TO STATE SURVEY AGENCIES.
  Inventory as of this Action Requested Previously Approved
09/30/1987 09/30/1987 09/30/1986
53 0 53
215 0 215
0 0 0

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

None
None


No

1
IC Title Form No. Form Name
MEDICARE - PSYCHIATRIC HOSPITAL MEDICARE SURVEY REPORT FORM HCFA-1537B

  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 53 0 0 0 0
Annual Time Burden (Hours) 215 215 0 0 0 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.
06/27/1986


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