Conflict of Interest and Ownership and Control Information

ICR 200005-0938-001

OMB: 0938-0795

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
ICR Details
0938-0795 200005-0938-001
Historical Active
HHS/CMS
Conflict of Interest and Ownership and Control Information
New collection (Request for a new OMB Control Number)   No
Regular
Approved without change 07/10/2000
Retrieve Notice of Action (NOA) 05/03/2000
This submission is approved for use in concept through 7/2001 under the condition that HCFA addresses the public comments in writing no later than 7/31/2000. After reviewing HCFA's response, OMB may request that HCFA amend this instrument and/or its burden estimate.
  Inventory as of this Action Requested Previously Approved
08/31/2001 08/31/2001
42 0 0
126 0 0
0 0 0

This information is required by Public Law 95-142 as a condition of participation in the Medicare program. The FIs and Carriers are contractually required as a condition for renewal of their contracts to submit to HCFA any ownership and control interest information.

None
None


No

1
IC Title Form No. Form Name
Conflict of Interest and Ownership and Control Information HCFA-R-312

  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 42 0 0 42 0 0
Annual Time Burden (Hours) 126 0 0 126 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
No

$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected

  No

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.
05/03/2000


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