Information Collection

Hospice Survey Report Form

IC 113599 under ICR 198909-0938-004 · OMB 0938-0379.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0379 can be found here:

Documents and Forms

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Information Collection (IC) Details

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IC Title:	HOSPICE SURVEY REPORT FORM	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Migrated

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	HCFA-449				No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 53	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	560	110	450
Annual IC Time Burden (Hours)	1,680	180	1,500
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.