(CMS-1880) Request for Certification as Supplier of Portable X-Ray and Portable X-Ray Survey Report Form

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-1880 Request for Certification as Supplier of Portable Xray Equipment	Form and Instruction	Modified	Repair queued
Form CMS-1880 Request for Certification as Supplier of Portable X-Ray and Portable X-Ray Survey Report Form	Form and Instruction	Modified	Repair queued
Supporting Statement A for CMS-1880 04.20.21.docx	Supporting Statement A	Uploaded 2021-08-13	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
7777	Request for Certification as Supplier of Portable X-Ray and Portable X-Ray Survey Report Form	Form and Instruction	Modified	Request for Certification as Supplier of Portable Xray Equipment
7777	Request for Certification as Supplier of Portable X-Ray and Portable X-Ray Survey Report Form	Form and Instruction	Modified

ICR Details

OMB Control No: 0938-0027	ICR Reference No: 202108-0938-004
Status: Historical Active	Previous ICR Reference No: 201803-0938-010
Agency/Subagency: HHS/CMS	Agency Tracking No: CCSQ
Title: (CMS-1880) Request for Certification as Supplier of Portable X-Ray and Portable X-Ray Survey Report Form
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 05/24/2022
Retrieve Notice of Action (NOA)	Date Received in OIRA: 08/13/2021
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2025	36 Months From Approved	05/31/2022
Responses	104	0	86
Time Burden (Hours)	26	0	22
Cost Burden (Dollars)	0	0	0

---

Abstract: The Medicare program requires portable X-ray suppliers to be surveyed for health and safety standards. The CMS-1880 is used by the surveyor to determine if a portable X-ray applicant meets the eligibility requirements.

---

Authorizing Statute(s): Statute at Large: 18 Stat. 1864
   Statute at Large: 18 Stat. 1875
   US Code: 42 USC 486.100 Name of Law: Conditions for Coverage: Portable X-ray Services
   Statute at Large: 18 Stat. 1861
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 22210	04/27/2021
30-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 44730	08/13/2021
Did the Agency receive public comments on this ICR? No

---

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

table that charts list of burden

IC Title	Form No.	Form Name
Request for Certification as Supplier of Portable X-Ray and Portable X-Ray Survey Report Form	CMS-1880	Request for Certification as Supplier of Portable Xray Equipment

---

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	104	86	0	0	18	0
Annual Time Burden (Hours)	26	22	0	0	4	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: No

Burden Reduction Due to:

Short Statement: The annual responses increased from 86 to 104. The annual time burden has increased by 4 hours and the annual cost burden has increased by $1,856.70.

---

Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     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? No

---

Common Form ICR:  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:

(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: 08/13/2021

---