STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

ICR 199207-0938-002

OMB: 0938-0391

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
113639 Migrated
ICR Details
0938-0391 199207-0938-002
Historical Active 198710-0938-003
HHS/CMS
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
Reinstatement with change of a previously approved collection   No
Regular
Approved without change 09/11/1992
Retrieve Notice of Action (NOA) 07/06/1992
Approved for use through 9/93 under the condition that the next submission for OMB review includes fully-updated CLIA surveyor guidanc supporting the use of these forms. This surveyor guidance should be identical to the surveyor guidance cleared under OMB No. 0938-0544 (exp. 2/93).
  Inventory as of this Action Requested Previously Approved
09/30/1993 09/30/1993
100,000 0 0
400,000 0 0
0 0 0

THIS FORM PROVIDES INFORMATION REGARDING DEFICIENCIES NOTED DURING PERIODIC FACILITY CERTIFICATION SURVEYS. INFORMATION FROM THIS FORM I USED TO MAKE DECISIONS CONCERNING CERTIFICATION AND RECERTIFICATION OF HEALTH CARE FACILITIES PARTICIPATING IN THE MEDICARE/MEDICAID PROGRAMS AND OF LABORATORIES REGULATED BY CLIA.

None
None


No

1
IC Title Form No. Form Name
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION HCFA 2567

  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 100,000 0 0 100,000 0 0
Annual Time Burden (Hours) 400,000 0 0 400,000 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.
07/06/1992


© 2024 OMB.report | Privacy Policy