Development of Survey Instrument for Special Populations

ICR 200107-0938-005

OMB: 0938-0844

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
0938-0844 200107-0938-005
Historical Active
HHS/CMS
Development of Survey Instrument for Special Populations
New collection (Request for a new OMB Control Number)   No
Regular
Approved without change 10/04/2001
Retrieve Notice of Action (NOA) 07/16/2001
Approved for use through 10/2003 with the understanding that because this effort does not employ a random sample and findings cannot be generalized, it cannot be used in isolation to develop an M+C case-mix methodology.
  Inventory as of this Action Requested Previously Approved
10/31/2003 10/31/2003
2,160 0 0
498 0 0
0 0 0

HCFA has developed a survey instrument for frail populations that is similar to the Health Outcomes survey (HOS). The collection of information under a pilot test is necessary to determine whether it is feasible to implement this survey for specialty organizations that serve frail populations. The pilot test will enable HCFA to assess response rates and the accuracy of responses under different approaches. If the pilot is successful, this survey could replace HOS for specialty organizations.

None
None


No

1
IC Title Form No. Form Name
Development of Survey Instrument for Special Populations HCFA-10024

  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 2,160 0 0 2,160 0 0
Annual Time Burden (Hours) 498 0 0 498 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
No

$0
Yes Part B of Supporting Statement
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.
07/16/2001


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