Approved for use
through 7/2000 under the condition that HCFA immediately
incorporates the new disclosure statements mandated by 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
08/31/2000
08/31/2000
07/31/1997
2,150
0
1,400
5,375
0
3,500
0
0
0
In order to participate in the
Medicare program, a hospice must meet certain Federal health and
safety conditions of participation. This form will be used by State
surveyors to record data about a hospice's compliance with these
conditions of participation in order to initiate the certification
or recertification process.
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.