HOSPITAL PROVIDER OF LONG TERM CARE SERVICES (SWING-BED) SURVEY REPORT FORM

ICR 199108-0938-009

OMB: 0938-0485

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
0938-0485 199108-0938-009
Historical Active 199103-0938-008
HHS/CMS
HOSPITAL PROVIDER OF LONG TERM CARE SERVICES (SWING-BED) SURVEY REPORT FORM
Extension without change of a currently approved collection   No
Regular
Approved without change 11/25/1991
Retrieve Notice of Action (NOA) 08/29/1991
  Inventory as of this Action Requested Previously Approved
11/30/1994 11/30/1994 09/30/1991
1,500 0 1,500
375 0 375
0 0 0

THIS SURVEY FORM IS AN INSTRUMENT USED BY THE STATE AGENCY TO RECORD DATA COLLECTED IN ORDER TO DETERMINE COMPLIANCE WITH INDIVIDUAL CONDITIONS OF PARTICIPATION AND REPORT IT TO THE FEDERAL GOVERNMENT.

None
None


No

1
IC Title Form No. Form Name
HOSPITAL PROVIDER OF LONG TERM CARE SERVICES (SWING-BED) SURVEY REPORT FORM HCFA-1537C

  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 1,500 1,500 0 0 0 0
Annual Time Burden (Hours) 375 375 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.
08/29/1991


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