PILOT TEST OF A HOME HEALTH AGENCY FUNCTIONAL ASSESSMENT INSTRUMENT

ICR 198904-0938-010

OMB: 0938-0543

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
0938-0543 198904-0938-010
Historical Active
HHS/CMS
PILOT TEST OF A HOME HEALTH AGENCY FUNCTIONAL ASSESSMENT INSTRUMENT
New collection (Request for a new OMB Control Number)   No
Regular
Approved without change 06/29/1989
Retrieve Notice of Action (NOA) 04/06/1989
Approved for use through 6/90 under the condition that the final evaluation of the pilot test is submitted to OMB prior to the submission of the revised survey protocol incorporating the functional assessment pursuant to OBRA 87.
  Inventory as of this Action Requested Previously Approved
06/30/1990 06/30/1990
240 0 0
431 0 0
0 0 0

PILOT TEST OF A FUNCTIONAL ASSESSMENT INSTRUMENT TO BE USED TO MEASURE CHANGE IN AN INDIVIDUAL'S CONDITION AS EFFECTED BY THE SERVICES PROVIDED BY A HOME HEALTH AGENCY. THE PURPOSE OF THE INSTRUMENT IS TO IDENTIFY AGENCIES PROVIDING ABOVE-STANDARD, STANDARD, AND BELOW-STANDA CARE.

None
None


No

1
IC Title Form No. Form Name
PILOT TEST OF A HOME HEALTH AGENCY FUNCTIONAL ASSESSMENT INSTRUMENT HFCF-R-128

  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 240 0 0 240 0 0
Annual Time Burden (Hours) 431 0 0 431 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.
04/06/1989


© 2024 OMB.report | Privacy Policy