Hospice Survey and Deficiencies Report Form (CMS-643)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-643-508 Hospice Survey and Deficiencies Report Form (CMS-643)	Form	Modified	Available
CMS-643 supporting statement.doc	Supporting Statement A	Uploaded 2009-05-28	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
8022	Hospice Survey and Deficiencies Report Form (CMS-643)	Form	Modified

ICR Details

OMB Control No: 0938-0379	ICR Reference No: 200906-0938-005
Status: Historical Active	Previous ICR Reference No: 200604-0938-010
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Hospice Survey and Deficiencies Report Form (CMS-643)
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 08/10/2009
	Date Received in OIRA: 06/11/2009
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2012	36 Months From Approved	08/31/2009
Responses	1,130	0	490
Time Burden (Hours)	1,130	0	1,225
Cost Burden (Dollars)	0	0	0

---

Abstract: 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.

---

Authorizing Statute(s): 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
  

Citations for New Statutory Requirements: None

---

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

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	74 FR 10917	03/13/2009
30-day Notice:	Federal Register Citation:	Citation Date:
	74 FR 25754	05/29/2009
Did the Agency receive public comments on this ICR? No

---

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

table that charts list of burden

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

---

ICR Summary of Burden

table that charts list 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	1,130	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

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: No

Burden Reduction Due to:

Short Statement:

---

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)? No

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  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:

(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: 06/11/2009

---