Psychiatric Unit Criteria Work Sheet, Rehabilitation Unit Criteria Work Sheet and Rehabilitation Hospital Criteria Work Sheet, and Supporting Regulations at 42 CFR 488.26 (CMS-437)

Forms and Documents

Document Name	Status
Form CMS-437 Psychiatric Unit Criteria Work Sheet, Rehabilitation Unit Criteria Work Sheet and Rehabilitation Hospital Criteria Work Sheet, and Supporting Regulations at 42 CFR 488.26 Form and Instruction	Modified
CMS-437 Supporting Statement 10-10-07.DOC Supporting Statement A	2007-10-10

IC Document Collections

IC ID	Document Title	Status
7996	Psychiatric Unit Criteria Work Sheet, Rehabilitation Unit Criteria Work Sheet and Rehabilitation Hospital Criteria Work Sheet, and Supporting Regulations at 42 CFR 488.26 Form and Instruction	Modified

ICR Details

OMB Control No: 0938-0358	ICR Reference No: 200710-0938-004
Status: Historical Active	Previous ICR Reference No: 200312-0938-003
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Psychiatric Unit Criteria Work Sheet, Rehabilitation Unit Criteria Work Sheet and Rehabilitation Hospital Criteria Work Sheet, and Supporting Regulations at 42 CFR 488.26 (CMS-437)
Type of Information Collection: Reinstatement with change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 02/22/2008
	Date Received in OIRA: 10/16/2007
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/28/2011	36 Months From Approved
Responses	1,333	0	0
Time Burden (Hours)	333	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The psychiatric unit criteria worksheet is necessary to verify that these units comply and remain in compliance with the exclusion criteria for the Medicare prospective payment system.

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Authorizing Statute(s): US Code: 42 USC 412 Name of Law: 25-27
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	72 FR 8167	02/23/2007
30-day Notice:	Federal Register Citation:	Citation Date:
	72 FR 46085	08/16/2007
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Psychiatric Unit Criteria Work Sheet, Rehabilitation Unit Criteria Work Sheet and Rehabilitation Hospital Criteria Work Sheet, and Supporting Regulations at 42 CFR 488.26	CMS-437	Psychiatric Unit Criteria Worksheet

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ICR Summary of Burden

	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	1,333	0	0	-1,277	0	2,610
Annual Time Burden (Hours)	333	0	0	-319	0	652
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: The submission is considered a reinstatement with change because the CMS-437A and CMS-437B were carved out and are now approved under 0938-0986.

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Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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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:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(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;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

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.

Certification Date: 10/11/2007

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