Hospice Survey and Deficiencies Report Form (CMS-643)

ICR 200906-0938-005

OMB: 0938-0379

Federal Form Document

Forms and Documents
IC Document Collections
IC ID
Document
Title
Status
8022 Modified
ICR Details
0938-0379 200906-0938-005
Historical Active 200604-0938-010
HHS/CMS
Hospice Survey and Deficiencies Report Form (CMS-643)
Extension without change of a currently approved collection   No
Regular
Approved with change 08/10/2009
Retrieve Notice of Action (NOA) 06/11/2009
  Inventory as of this Action Requested Previously Approved
08/31/2012 36 Months From Approved 08/31/2009
1,130 0 490
1,130 0 1,225
0 0 0

In order to participate in the Medicare program, a hospice must meet certain Federal health and safety conditions of participation. This form will be used by State surveyors to record data about a hospice's compliance with these conditions of participation in order to initiate the certification or recertification process.

US Code: 42 USC 488.26 Name of Law: Determining Compliance
   US Code: 42 USC 442.30 Name of Law: Agreement as evidence of Certification
  
None

Not associated with rulemaking

  74 FR 10917 03/13/2009
74 FR 25754 05/29/2009
No

1
IC Title Form No. Form Name
Hospice Survey and Deficiencies Report Form (CMS-643) CMS-643-508 Hospice Survey and Deficiencies Report

  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 1,130 490 0 0 640 0
Annual Time Burden (Hours) 1,130 1,225 0 0 -95 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$0
No
No
Uncollected
Uncollected
No
Uncollected
Melissa Musotto 4107866962

  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.
06/11/2009


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