SCREENING MAMMOGRAPHY SERVICES DATA REPORT

ICR 199204-0938-002

OMB: 0938-0611

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
IC ID
Document
Title
Status
114069 Migrated
ICR Details
0938-0611 199204-0938-002
Historical Active
HHS/CMS
SCREENING MAMMOGRAPHY SERVICES DATA REPORT
New collection (Request for a new OMB Control Number)   No
Regular
Approved without change 06/25/1992
Retrieve Notice of Action (NOA) 04/17/1992
Approved for use through 10/92 under the condition that the next submission for OMB review is consistent with the final rulemaking setting forth Medicare Conditions of Coverage for Mammography Screening.
  Inventory as of this Action Requested Previously Approved
10/31/1992 10/31/1992
10,000 0 0
2,500 0 0
0 0 0

THE SCREENING MAMMOGRAPHY SERVICES DATA REPORT FORM IS A FACILITY IDENTIFICATION AND SCREENING FORM USED TO INITIATE THE CERTIFICATION PROCESS FOR SUPPLIERS OF SCREENING MAMMOGRAPHY SERVICES AND TO DETERMI IF THE SUPPLIER HAS THE MINIMAL REQUIRED PERSONNEL TO PARTICIPATE IN T MEDICARE PROGRAM. THE FORM ALSO IDENTIFIES THE DATE AND TYPE OF FEDER SURVEY CONDUCTED AND THE INDIVIDUAL(S) AND TITLE(S) OF INDIVIDUAL(S)

None
None


No

1
IC Title Form No. Form Name
SCREENING MAMMOGRAPHY SERVICES DATA REPORT HCFA-292

  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 10,000 0 0 10,000 0 0
Annual Time Burden (Hours) 2,500 0 0 2,500 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.
04/17/1992


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