Approved for use
through 1/2000 under the condition that the forms/instructions
include the new disclosure statements mandated pursuant to the
Paperwork Reduction Act of 1995. For the public record, HCFA must
submit to OMB the revised forms/instructions.
Inventory as of this Action
Requested
Previously Approved
01/31/2000
01/31/2000
12/31/1996
3,800
0
2,400
1,425
0
900
0
0
0
HCFA-377 and 378 is used for
facilities participating in the Medicare program as ASCs. The State
survey agency uses these forms as a instrument to record data in
order to determine supplier compliance with individual conditions
of coverage. This information is reported to HCFA.
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.