(CMS-359/360) Comprehensive Outpatient Rehabilitation Facility (CORF) Certification and Survey Forms

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-360 COMPREHENSIVE OUTPATIENT REHABILITATION FACILITY SURVEY REPORT	Form and Instruction	Modified	Available
Form CMS-359 Comprehensive Outpatient Rehab Facility Request Form	Form and Instruction	Modified	Available
CMS-359 -360 - Supporting Statement _2015.docx	Supporting Statement A	Uploaded 2016-03-21	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
7917	Comprehensive Outpatient Rehabilitation Facility (CORF) Eligibility and Survey Forms and Information Collection Requirements in 42 CFR 485.56, 485.58, 485.60, 485.64...	Form and Instruction	Modified	COMPREHENSIVE OUTPATIENT REHABILITATION FACILITY SURVEY REPORT
7917	Comprehensive Outpatient Rehabilitation Facility (CORF) Eligibility and Survey Forms and Information Collection Requirements in 42 CFR 485.56, 485.58, 485.60, 485.64...	Form and Instruction	Modified	Comprehensive Outpatient Rehab Facility Request Form

ICR Details

OMB Control No: 0938-0267	ICR Reference No: 201603-0938-013
Status: Historical Active	Previous ICR Reference No: 201209-0938-005
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: (CMS-359/360) Comprehensive Outpatient Rehabilitation Facility (CORF) Certification and Survey Forms
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: 10/05/2016
Retrieve Notice of Action (NOA)	Date Received in OIRA: 03/21/2016
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2019	36 Months From Approved	10/31/2016
Responses	50	0	42
Time Burden (Hours)	123	0	137
Cost Burden (Dollars)	0	0	0

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Abstract: In order to participate in the Medicare program as a CORF, providers must meet federal conditions of participation. The certification form is needed to determine if providers meet at least preliminary requirements. The survey form is used to record provider compliance with the individual conditions and report findings to CMS.

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Authorizing Statute(s): US Code: 42 USC 485.50 Name of Law: Conditions of Participation: CORF
  

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:
	81 FR 92	01/04/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 12903	03/11/2016
Did the Agency receive public comments on this ICR? No

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

table that charts list of burden

IC Title	Form No.	Form Name
Comprehensive Outpatient Rehabilitation Facility (CORF) Eligibility and Survey Forms and Information Collection Requirements in 42 CFR 485.56, 485.58, 485.60, 485.64...	CMS-360, CMS-359	Comprehensive Outpatient Rehab Facility Request Form ,   COMPREHENSIVE OUTPATIENT REHABILITATION FACILITY SURVEY REPORT

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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	50	42	0	0	8	0
Annual Time Burden (Hours)	123	137	0	0	-14	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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: Burden changes are related to changes in the number of forms completed annually and an update to wage data.

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Annual Cost to Federal Government: $30

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: 03/21/2016

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