Hospice Survey and Deficiencies Report Form (CMS-643)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0379 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-643 Hospice Survey and Deficiencies Report Form (CMS-643) Form
CMS-643 Hospice Survey and Deficiencies Report CMS-643 [rev 7-18-2012].pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Hospice Survey and Deficiencies Report Form (CMS-643)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-643	Hospice Survey and Deficiencies Report	CMS-643 [rev 7-18-2012].pdf		Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 3,644	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	1,217	87	1,130
Annual IC Time Burden (Hours)	1,217	87	1,130
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.