Field Testing of the Uniform Needs Assessment Instrument

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
8268	Field Testing of the Uniform Needs Assessment Instrument Form	Migrated

ICR Details

OMB Control No: 0938-0680	ICR Reference No: 199510-0938-002
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Field Testing of the Uniform Needs Assessment Instrument
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 01/24/1996
	Date Received in OIRA: 10/31/1995
Terms of Clearance: The field test of the uniform needs assessment instrument is approved for use through 1/98 under the following conditions: 1) HCFA conducts a more extensive pilot prior to its consideration of any Federally mandated adoption of this instrument; 2) the survey protocol contains provider follow-up pertaining to the burden imposed on facilities (both in time and resources) and the instrument sections most difficult and costly to complete; 3) prior to fielding the instrument and no later than 2/5/96, HCFA submits materials to OMB comparing this instrument to the nursing home Minimum Data Set (MDS). During the course of these discussions, OMB may request refinements of the instrument; and 4) for the public record, HCFA responds to the designated items in the attached agenda from its OMB conference call dated 1/24/96 .

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/1998	01/31/1998
Responses	840	0	0
Time Burden (Hours)	1,050	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The validity, reliability, and administrative feasibility of the Uniform Needs Assessment Instrument will be tested in the small-scale trial. Also, a high-risk screener will be developed to identify hospital patients in need of extensive discharge planning. Testing will be done in two phases approximately one year apart. Each phase will involve 12 provider sits, 420 patients, and 840 total assessments.

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Authorizing Statute(s): None

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:

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Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Field Testing of the Uniform Needs Assessment Instrument	HCFA-A-180

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ICR Summary of Burden

	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	840	0	0	840	0	0
Annual Time Burden (Hours)	1,050	0	0	1,050	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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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:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(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;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

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.

Certification Date: 10/31/1995

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