MEDICARE ESRD OUTCOME SURVEY REPORT FORM

ICR 198611-0938-001

OMB: 0938-0492

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
113870 Migrated
ICR Details
0938-0492 198611-0938-001
Historical Active
HHS/CMS
MEDICARE ESRD OUTCOME SURVEY REPORT FORM
New collection (Request for a new OMB Control Number)   No
Regular
Approved without change 01/14/1987
Retrieve Notice of Action (NOA) 11/03/1986
1.BEFORE A FUTURE EXTENSION WILL BE GRANTED, HCFA MUST GIVE OMB A REPORT DESCRIBING THE RESULTS OF THE TEST IMPLEMENTATION OF THE SURVEY.
  Inventory as of this Action Requested Previously Approved
04/30/1988 04/30/1988
165 0 0
330 0 0
0 0 0

THIS INFORMATION COLLECTION IS A PATIENT-OUTCOME SURVEY REPORT FORM TO BE FIELD-TESTED IN END STAGE RENAL DISEASE FACILITIES.

None
None


No

1
IC Title Form No. Form Name
MEDICARE ESRD OUTCOME SURVEY REPORT FORM HCFA 3427, (TEST)

  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 165 0 0 165 0 0
Annual Time Burden (Hours) 330 0 0 330 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.
11/03/1986


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