EARLY AND PERIODIC SCREENING DIAGNOSTIC AND TREATMENT (EPSDT) REPORT

ICR 199305-0938-002

OMB: 0938-0354

Federal Form Document

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ICR Details
0938-0354 199305-0938-002
Historical Active 199004-0938-002
HHS/CMS
EARLY AND PERIODIC SCREENING DIAGNOSTIC AND TREATMENT (EPSDT) REPORT
Revision of a currently approved collection   No
Regular
Approved without change 08/04/1993
Retrieve Notice of Action (NOA) 05/13/1993
This information collection is approved through 7-95 under the following condition: HCFA will add a burden estimate statement to the instructions accompanying the 416. Upon the next submission, HCFA will also provide information on the success of the States in collecting screening information on children in managed or continuing care.
  Inventory as of this Action Requested Previously Approved
09/30/1995 09/30/1995 06/30/1993
56 0 56
1,568 0 1,176
0 0 0

CONGRESS AND HCFA ARE INTERESTED IN THE EPSDT PROGRAM'S EFFECTIVENESS IMPROVING THE HEALTH OF MEDICAID-ELIGIBLE CHILDREN. THE HCFA-416, SUBMITTED BY ALL 56 MEDICAID JURISDICTIONS, SUPPLIES DATA FOR PROMPT, ACCURATE MONITORING OF EPSDT ACTIVITIES.

None
None


No

1
IC Title Form No. Form Name
EARLY AND PERIODIC SCREENING DIAGNOSTIC AND TREATMENT (EPSDT) REPORT HCFA-416

  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 56 56 0 0 0 0
Annual Time Burden (Hours) 1,568 1,176 0 392 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.
05/13/1993


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