Request for Certification as Supplier of Portable X-Ray and Portable X-Ray Survey Report Form

ICR 200512-0938-006

OMB: 0938-0027

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
ICR Details
0938-0027 200512-0938-006
Historical Active 200207-0938-001
HHS/CMS
Request for Certification as Supplier of Portable X-Ray and Portable X-Ray Survey Report Form
Extension without change of a currently approved collection   No
Regular
Approved without change 02/23/2006
Retrieve Notice of Action (NOA) 12/16/2005
  Inventory as of this Action Requested Previously Approved
02/28/2009 02/28/2009 02/28/2006
98 0 98
172 0 172
0 0 0

The Medicare program requires portable X-ray suppliers to be surveyed for health and safety standards. The CMS-1882 is the survey form that records survey results. The CMS-1880 is used by the surveyor to determine if a portable X-ray applicant meets the eligibility requirements.

None
None


No

1
IC Title Form No. Form Name
Request for Certification as Supplier of Portable X-Ray and Portable X-Ray Survey Report Form 1880-1882

  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 98 98 0 0 0 0
Annual Time Burden (Hours) 172 172 0 0 0 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.
12/16/2005


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