Information Collection

Hospice Survey and Deficiencies Report Form and Supporting Regulations -- 42 CFR 488, 488.26(c), 442.30(a)(4), 442 subparts B, C, D, E, and F

IC 8019 under ICR 199704-0938-001 · OMB 0938-0379.

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Information Collection (IC) Details

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IC Title:	Hospice Survey and Deficiencies Report Form and Supporting Regulations -- 42 CFR 488, 488.26(c), 442.30(a)(4), 442 subparts B, C, D, E, and F	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Migrated

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	HCFA-643				No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2,150	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	2,150	750	1,400
Annual IC Time Burden (Hours)	5,375	1,875	3,500
Annual IC Cost Burden (Dollars)	0	0	0

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Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.