FIRE SAFETY SURVEY REPORT FORMS

ICR 199209-0938-004

OMB: 0938-0242

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
113224 Migrated
ICR Details
0938-0242 199209-0938-004
Historical Active 199103-0938-015
HHS/CMS
FIRE SAFETY SURVEY REPORT FORMS
Reinstatement with change of a previously approved collection   No
Regular
Approved without change 12/02/1992
Retrieve Notice of Action (NOA) 09/03/1992
  Inventory as of this Action Requested Previously Approved
12/31/1995 12/31/1995
23,574 0 0
20,537 0 0
0 0 0

THESE SURVEY FORMS ARE USED BY THE STATE AGENCY TO RECORD DATA COLLECT TO DETERMINE COMPLIANCE WITH INDIVIDUAL CONDITIONS DURING FIRE SAFETY SURVEYS AND REPORT IT TO THE FEDERAL GOVERNMENT.

None
None


No

1
IC Title Form No. Form Name
FIRE SAFETY SURVEY REPORT FORMS HCFA-2786, A-D, F, G, H, J, K, L, M

  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 23,574 0 0 23,574 0 0
Annual Time Burden (Hours) 20,537 0 0 20,537 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.
09/03/1992


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