Uncompensated Services Assurance Report

ICR 201206-0915-005

OMB: 0915-0077

Federal Form Document

Forms and Documents
Document
Name
Status
Form and Instruction
Modified
Supplementary Document
2009-04-13
Supplementary Document
2009-04-13
Supporting Statement A
2012-08-16
IC Document Collections
ICR Details
0915-0077 201206-0915-005
Historical Active 200904-0915-001
HHS/HSA
Uncompensated Services Assurance Report
Extension without change of a currently approved collection   No
Regular
Approved with change 08/31/2012
Retrieve Notice of Action (NOA) 06/25/2012
In accordance with 5 CR 1320, the information collection is approved. However, the agency is reminded that they must properly classify the type of burden (i.e., reporting, recordkeeping, third party disclosure) in the ROCIS worksheet.
  Inventory as of this Action Requested Previously Approved
08/31/2015 36 Months From Approved 08/31/2012
6,441 0 8,873
10,786 0 14,679
0 0 0

Under the Hill-Burton Act, the government provides grants and loans for construction or renovation of health care facilities under the condition that facilitates provide services to persons unable to pay. Facilitates are required to provide assurances that the required level of uncompensated care is being provided, and that certain notification and record keeping procedures are being followed.

US Code: 42 USC 300 Name of Law: 300s-6: Public Health Service Act
  
None

Not associated with rulemaking

  77 FR 7593 02/13/2012
77 FR 24963 04/26/2012
No

1
IC Title Form No. Form Name
Uncompensated Services Assurance Report 710 Uncompensated Services Assurance 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 6,441 8,873 0 0 -2,432 0
Annual Time Burden (Hours) 10,786 14,679 0 0 -3,893 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$7,407
No
No
No
No
No
Uncollected
Carla Haddad 301 443-0165 [email protected]

  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.
06/20/2012


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