MEDICARE/MEDICAID - LONG TERM CARE SURVEY REPORT FORMS

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
113656	MEDICARE/MEDICAID - LONG TERM CARE SURVEY REPORT FORMS Form	Migrated

ICR Details

OMB Control No: 0938-0400	ICR Reference No: 198708-0938-006
Status: Historical Active	Previous ICR Reference No: 198608-0938-017
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: MEDICARE/MEDICAID - LONG TERM CARE SURVEY REPORT FORMS
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 11/05/1987
	Date Received in OIRA: 08/06/1987
Terms of Clearance: Approved through 2/88 under the condition that prior to the next submission, the Department: o reexamines the survey forms for indicators that do not apply to ICFs under existing regulation o revises the forms to clarify that these indicators should only apply to SNFs. o eliminates indicators not required by existing implementing regulations o revises indicator language so that it is identical to regulatory language and does not incorrectly paraphrase or interpret regulatory intent o revises the forms so that the same deficiencies will not be counted twice (once in Part A and another time in Part B)

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/28/1988	02/28/1988	11/30/1987
Responses	46,175	0	16,500
Time Burden (Hours)	12,625	0	58,800
Cost Burden (Dollars)	0	0	0

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Abstract: 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.

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Authorizing Statute(s): None

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:

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Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

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

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ICR Summary of Burden

	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	46,175	16,500	0	0	29,675	0
Annual Time Burden (Hours)	12,625	58,800	0	0	-46,175	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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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:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(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;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

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.

Certification Date: 08/06/1987

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