APPLICATION TO PROVIDE COMMUNITY SUPPORTED LIVING ARRANGEMENTS (CSLA) SERVICES

ICR 199106-0938-001

OMB: 0938-0585

Federal Form Document

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Document
Name
Status
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ICR Details
0938-0585 199106-0938-001
Historical Active
HHS/CMS
APPLICATION TO PROVIDE COMMUNITY SUPPORTED LIVING ARRANGEMENTS (CSLA) SERVICES
New collection (Request for a new OMB Control Number)   No
Regular
Approved without change 06/21/1991
Retrieve Notice of Action (NOA) 06/20/1991
  Inventory as of this Action Requested Previously Approved
08/31/1991 08/31/1991
50 0 0
4,000 0 0
0 0 0

THIS APPLICATION WILL BE USED BY STATES SEEKING SELECTION TO PARTICIPA TO PROVIDE COMMUNITY SUPPORTED LIVING ARRANGEMENTS (CSLA) SERVICES FOR THE MENTALLY RETARDED OR THOSE WITH RELATED CONDITIONS. THE STATES MU COMPLETE AN APPLICATION TO BE SELECTED TO PARTICIPATE IN THIS PROGRAM.

None
None


No

1
IC Title Form No. Form Name
APPLICATION TO PROVIDE COMMUNITY SUPPORTED LIVING ARRANGEMENTS (CSLA) SERVICES HCFA-332

  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 50 0 0 50 0 0
Annual Time Burden (Hours) 4,000 0 0 4,000 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.
06/20/1991


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