Information Collection

Hospice Survey and Deficiencies Report Form (CMS-643)

IC 8022 under ICR 201907-0938-005 · OMB 0938-0379.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
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.pdf	Form
CMS-643 Response_to_Public_Comments.doc response to comments	IC Document

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:

table that charts list of 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.pdf		Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 4,801

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	1,600	275	1,325
Annual IC Time Burden (Hours)	1,600	275	1,325
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
response to comments	CMS-643 Response_to_Public_Comments.doc	07/29/2019

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