Information Collection Request
Hospice Survey and Deficiencies Report Form (CMS-643)
ICR 202212-0938-011 · OMB 0938-0379 · Received in OIRA
⚠️ Notice: This information collection may be outdated. More recent filings for OMB 0938-0379 can be found here:
Forms and Documents
| Document | Type | Status | Availability |
|---|---|---|---|
 Form CMS-643 Hospice Survey and Deficiencies Report Form (CMS-643) |
Form | Modified | Repair queued |
 CMS-643 Supporting Statement 11.29.22.docx |
Supporting Statement A | Uploaded 2022-12-13 | Repair queued |
IC Document Collections
| IC ID | Collection | Type | Status | Form |
|---|---|---|---|---|
| 8022 |  Hospice Survey and Deficiencies Report Form (CMS-643) |
Form | Modified |
ICR Details
| Status | Received in OIRA |
|---|---|
| Agency/Subagency | HHS/CMS |
| OMB Control No | 0938-0379 |
| Type of Information Collection | Reinstatement with change of a previously approved collection |
| Previous ICR Reference No | 201907-0938-005 |
| Agency Tracking No | CCSQ |
| Date Submitted to OIRA | 1969-12-31 |
| Requested Expiration Date | 1969-12-31 |