Information Collection

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

IC 8020 under ICR 200006-0938-007 · OMB 0938-0379.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0379 can be found here:

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Information Collection (IC) Details

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IC Title:	Hospice Survey and Deficiencies Report Form and Supporting Regulations at 42 CFr Part 418.1 - 418.405	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Migrated

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

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

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2,293	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	2,293	143	2,150
Annual IC Time Burden (Hours)	5,733	358	5,375
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.