Hospice Survey and Deficiencies Report Form and Supporting Regulations at 42 CFr Part 418.1 - 418.405

ICR 200006-0938-007

OMB: 0938-0379

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
ICR Details
0938-0379 200006-0938-007
Historical Active 199704-0938-001
HHS/CMS
Hospice Survey and Deficiencies Report Form and Supporting Regulations at 42 CFr Part 418.1 - 418.405
Extension without change of a currently approved collection   No
Regular
Approved without change 08/10/2000
Retrieve Notice of Action (NOA) 06/14/2000
  Inventory as of this Action Requested Previously Approved
09/30/2003 09/30/2003 08/31/2000
2,293 0 2,150
5,733 0 5,375
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 ued 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.

None
None


No

1
IC Title Form No. Form Name
Hospice Survey and Deficiencies Report Form and Supporting Regulations at 42 CFr Part 418.1 - 418.405 643

  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 2,293 2,150 0 0 143 0
Annual Time Burden (Hours) 5,733 5,375 0 0 358 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
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.
06/14/2000


© 2024 OMB.report | Privacy Policy