UNCOMPENSATED SERVICES REPORTING AND RECORDKEEPING

ICR 198708-0915-003

OMB: 0915-0077

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
110244 Migrated
ICR Details
0915-0077 198708-0915-003
Historical Active 198612-0915-001
HHS/HSA
UNCOMPENSATED SERVICES REPORTING AND RECORDKEEPING
Revision of a currently approved collection   No
Regular
Approved without change 11/02/1987
Retrieve Notice of Action (NOA) 08/06/1987
  Inventory as of this Action Requested Previously Approved
04/30/1988 04/30/1988 12/31/1987
575,386 0 575,386
1,704,142 0 1,893,669
0 0 0

HEALTH CARE FACILITIE WHICH HAVE RECEIVED FUNDS UNDER TITLES V AND XVI OF THE PHS ACT ARE REQUIRED TO PROVIDE PRESCRIBED AMOUNTS OF CARE TO PERSONS UNABLE TO PA AND TO SUBMIT TO THE SECRETARY DATA AND INFORMATION WHICH REASONABLY DEMONSTRATES COMPLIANCE WITH THIS REQUIREMENTS. INDIVIDUALS DENIED SU CARE HAVE A RIGHT TO APPEAL THAT DENIAL TO THE SECRETARY.

None
None


No

1
IC Title Form No. Form Name
UNCOMPENSATED SERVICES REPORTING AND RECORDKEEPING HRSA-710

  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 575,386 575,386 0 0 0 0
Annual Time Burden (Hours) 1,704,142 1,893,669 0 -493,683 304,156 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
Yes

$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.
08/06/1987


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