Home and Community-Based Services Waiver Requests

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
8068	Home and Community-Based Services Waiver Requests Form	Migrated

ICR Details

OMB Control No: 0938-0449	ICR Reference No: 199602-0938-005
Status: Historical Active	Previous ICR Reference No: 199410-0938-005
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Home and Community-Based Services Waiver Requests
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 04/15/1996
	Date Received in OIRA: 02/15/1996
Terms of Clearance: This information collection is approved through 5-97 under the following conditions: Upon the next submisstion, HCFA will submit a proposal to streamline the home and community-based waiver process for States. Initiatives to streamline the process could include: facilitating the electronic transmission of the form, creation of a preprint with simple response boxes, modification of regulations to create permanent authorities and elimination of the need for waivers of specific provisions. In the event that legislation modifying the waiver process is passed before 5-97, HCFA will submit the modified information collection to OMB upon completion. HCFA failed to respond to previous terms of conditions and as a result OMB will not review any submission that does not address these terms and include either changes or a proposal to streamline the process.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/1999	04/30/1999	04/30/1996
Responses	140	0	140
Time Burden (Hours)	12,600	0	12,600
Cost Burden (Dollars)	0	0	0

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Abstract: Under a Secretarial waiver, States may offer a wide array of home- and community-based services to individuals who would otherwise require institutionalization. States requesting a waiver must provide certain assurances, documentation, and cost and utilization estimates which are reviewed, approved, and maintained for the purpose of identifying/verifying States' compliance with such statutory and regulatory requirements.

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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
Home and Community-Based Services Waiver Requests	HCFA-8003

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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	140	140	0	0	0	0
Annual Time Burden (Hours)	12,600	12,600	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

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

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? No

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: 02/15/1996

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