Home Health and Hospice Survey and Interviews

Fast Track Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0990-0379 can be found here:

Documents and Forms

Document Name Document Type
Survey.docx Other-survey
Interview Guide.docx Other-guide
SSA_0990-0391 Generic ASPR TRACIE Home Health and Hospice Interviews 1-....docx SS-A IC Document
SSB_0990-0391 Generic ASPR TRACIE Home Health and Hospice 1-7-19.docx SS-B IC Document
0990-0391 ASPR TRACIE Home Health and Hospice_Generic_Memo Template.doc Memo IC Document

Information Collection (IC) Details

IC Title:	Home Health and Hospice Survey and Interviews	Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-survey			Survey.docx		Yes	Yes	Fillable Fileable
Other-guide			Interview Guide.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 250	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	250	250
Annual IC Time Burden (Hours)	75	75
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
SS-A	SSA_0990-0391 Generic ASPR TRACIE Home Health and Hospice Interviews 1-....docx	01/18/2019
SS-B	SSB_0990-0391 Generic ASPR TRACIE Home Health and Hospice 1-7-19.docx	01/18/2019
Memo	0990-0391 ASPR TRACIE Home Health and Hospice_Generic_Memo Template.doc	01/18/2019

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