Uncompensated Services Assurance Report

Forms and Documents

Document Name	Status
Form 710 Uncompensated Services Assurance Report Form and Instruction	Modified
CurrentRegulations-0077.pdf Supplementary Document	2009-04-13
AuthorizingLegislation-0077.pdf Supplementary Document	2009-04-13
FINAL SupportingStatement A - CORRECTED AND REVISED.doc Supporting Statement A	2012-08-16

IC Document Collections

IC ID	Document Title	Status
6349	Uncompensated Services Assurance Report Form and Instruction	Modified

ICR Details

OMB Control No: 0915-0077	ICR Reference No: 201206-0915-005
Status: Historical Active	Previous ICR Reference No: 200904-0915-001
Agency/Subagency: HHS/HSA	Agency Tracking No:
Title: Uncompensated Services Assurance Report
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: 08/31/2012
	Date Received in OIRA: 06/25/2012
Terms of Clearance: 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
Expiration Date	08/31/2015	36 Months From Approved	08/31/2012
Responses	6,441	0	8,873
Time Burden (Hours)	10,786	0	14,679
Cost Burden (Dollars)	0	0	0

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Abstract: 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.

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Authorizing Statute(s): US Code: 42 USC 300 Name of Law: 300s-6: Public Health Service Act
  

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:
	77 FR 7593	02/13/2012
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 24963	04/26/2012
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
Uncompensated Services Assurance Report	710	Uncompensated Services Assurance Report

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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	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

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:

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Annual Cost to Federal Government: $7,407

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]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

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: 06/20/2012

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