Information Collection

Home Health Agency Survey and Deficiencies Report

IC 7990 under ICR 202102-0938-001 · OMB 0938-0355.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0355 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-1572 Home Health Agency Survey and Deficiencies Report	Form and Instruction
CMS-1572 Home Health Agency And Deficiences Report cms1572a-e_508_Compliant (5-2-2017).pdf	Form and Instruction
CMS-1572 Home Health Agency And Deficiences Report cms1572a-e_508_Compliant (5-2-2017).pdf	Form and Instruction
Crosswalk.Form1572 HHA Survey Report.docx Crosswalk	IC Document
Crosswalk.Form1572 HHA Survey Report.docx Crosswalk	IC Document

IC Title:

Home Health Agency Survey and Deficiencies Report

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 488.26 42 CFR 442.30

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 and Instruction	CMS-1572	Home Health Agency And Deficiences Report	cms1572a-e_508_Compliant (5-2-2017).pdf		No		Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 3,833

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	3,833	438	3,395
Annual IC Time Burden (Hours)	1,917	1,068	849
Annual IC Cost Burden (Dollars)	142,778	142,778	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Crosswalk	Crosswalk.Form1572 HHA Survey Report.docx	02/02/2021

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