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Hospice Survey and Deficiencies Report Form
Hospice Survey and Deficiencies Report Form
OMB: 0938-0379
IC ID: 8022
OMB.report
HHS/CMS
OMB 0938-0379
ICR 200604-0938-010
IC 8022
( )
⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0379 can be found here:
2022-12-27 - Reinstatement with change of a previously approved collection
2019-08-13 - Reinstatement without change of a previously approved collection
Documents and Forms
Document Name
Document Type
no available documents/forms check other ICs listed under this ICR
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Hospice Survey and Deficiencies Report Form
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
CMS-643
No
No
Federal Enterprise Architecture Business Reference Module
Line of Business:
Subfunction:
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
2,511
Number of Respondents for Small Entity:
0
Affected Public:
Private Sector
Private Sector:
Not-for-profit institutions
Percentage of Respondents Reporting Electronically:
0 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
490
0
0
15
0
475
Annual IC Time Burden (Hours)
1,225
0
0
-4,508
0
5,733
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.