INTAKE AND ASSESSMENT SURVEY PACKAGE FOR THE COMMUNITY NURSING ORGANIZATION DEMONSTRATION

ICR 199310-0938-005

OMB: 0938-0644

Federal Form Document

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Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
ICR Details
0938-0644 199310-0938-005
Historical Active
HHS/CMS
INTAKE AND ASSESSMENT SURVEY PACKAGE FOR THE COMMUNITY NURSING ORGANIZATION DEMONSTRATION
New collection (Request for a new OMB Control Number)   No
Regular
Approved without change 12/16/1993
Retrieve Notice of Action (NOA) 10/25/1993
  Inventory as of this Action Requested Previously Approved
12/31/1996 12/31/1996
4,032 0 0
4,080 0 0
0 0 0

THE INTAKE AND ASSESSMENT SURVEY INSTRUMENT WILL COLLECT INFORMATION O APPROXIMATELY 4800 INDIVIDUALS ENROLLED IN THE COMMUNITY NURSING ORGANIZATION DEMONSTRATION. THE INFORMATION COLLECTED WILL BE USED TO EVALUATE THE EFFECTIVENESS AND OUTCOMES OF THE DEMONSTRATION PROJECT.

None
None


No

1
IC Title Form No. Form Name
INTAKE AND ASSESSMENT SURVEY PACKAGE FOR THE COMMUNITY NURSING ORGANIZATION DEMONSTRATION HCFA-644

  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 4,032 0 0 4,032 0 0
Annual Time Burden (Hours) 4,080 0 0 4,080 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.
10/25/1993


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