Home and Community Based Services (HCBS) Incident Management Survey (CMS-10692)

ICR 201903-0938-008

OMB: 0938-1362

Federal Form Document

Forms and Documents
Document
Name
Status
Form and Instruction
New
Supplementary Document
2019-03-15
Supporting Statement B
2019-03-15
Supporting Statement A
2019-03-15
IC Document Collections
IC ID
Document
Title
Status
235360 New
ICR Details
0938-1362 201903-0938-008
Active
HHS/CMS CMCS
Home and Community Based Services (HCBS) Incident Management Survey (CMS-10692)
New collection (Request for a new OMB Control Number)   No
Regular
Approved with change 06/13/2019
Retrieve Notice of Action (NOA) 03/15/2019
  Inventory as of this Action Requested Previously Approved
06/30/2022 36 Months From Approved
102 0 0
153 0 0
0 0 0

States will be requested to complete and submit the survey which is intended to identify methods and promising practices for identifying, reporting, tracking, and resolving incidents of abuse, neglect, and exploitation. The results of the survey will also be used to review the strengths and weaknesses of each state’s incident management system and will inform guidance to help ensure states comply with sections 1902(a)(30)(A) and 1915(c)(2)(A) of the Social Security Act.

US Code: 42 USC 1915(c)(2)(A) Name of Law: Social Security Act
  
None

Not associated with rulemaking

  83 FR 64346 12/14/2018
84 FR 9527 03/15/2019
Yes

1
IC Title Form No. Form Name
HCBS Incident Management Survey CMS-10692 HCBS Incident Management Survey

  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 102 0 0 102 0 0
Annual Time Burden (Hours) 153 0 0 153 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
Miscellaneous Actions
No
Not applicable. This is a new submission

$192,705
Yes Part B of Supporting Statement
    No
    No
No
No
No
Uncollected
Mitch Bryman 410 786-5258 [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.
03/15/2019


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