MEDICARE HISTOCOMPATIBILITY TESTING LABORATORIES SURVEY REPORT FORM

ICR 198906-0938-005

OMB: 0938-0376

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
0938-0376 198906-0938-005
Historical Active 198605-0938-014
HHS/CMS
MEDICARE HISTOCOMPATIBILITY TESTING LABORATORIES SURVEY REPORT FORM
Revision of a currently approved collection   No
Regular
Approved without change 08/23/1989
Retrieve Notice of Action (NOA) 06/30/1989
  Inventory as of this Action Requested Previously Approved
08/31/1990 08/31/1990 07/31/1989
200 0 53
200 0 200
0 0 0

THIS SURVEY FORM IS AN INSTRUMENT USED BY THE STATE AGENCY SURVEYOR TO RECORD DATA COLLECTED DURING THE COURSE OF A SURVEY. THIS INFORMATION IS NEEDED TO DETERMINE FACILITY COMPLIANCE WITH CONDITIONS OF PARTICIPATION FOR MEDICARE. THE DATA IS THEN REPORTED TO THE FEDERAL GOVERNMENT.

None
None


No

1
IC Title Form No. Form Name
MEDICARE HISTOCOMPATIBILITY TESTING LABORATORIES SURVEY REPORT FORM HCFA-445

  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 200 53 0 147 0 0
Annual Time Burden (Hours) 200 200 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.
06/30/1989


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