Information Collection

Home Health Agency Survey and Deficiencies Report

IC 7990 under ICR 202301-0938-012 · OMB 0938-0355.

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 CMS 1572. 12.19.22.docx	Form and Instruction
CMS-1572 Home Health Agency And Deficiences Report CMS 1572. 12.19.22.docx	Form and Instruction
CMS-1572 Home Health Agency and Deficiencies Report CMS 1572. 12.21.22.pdf	Form and Instruction
CMS-1572 Home Health Agency and Deficiencies Report CMS 1572. 12.21.22.pdf	Form and Instruction
Change Crosswalk for CMS-1572. 11.01.22.docx Crosswalk	IC Document
Change Crosswalk for CMS-1572. 11.01.22.docx Crosswalk	IC Document
CMS.1572 form COMPARE VERSION. 01.26.23.docx Compare version of CMS-1572	IC Document
CMS.1572 form COMPARE VERSION. 01.26.23.docx Compare version of CMS-1572	IC Document

IC Title:

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	CMS 1572. 12.19.22.docx		No		Fillable Fileable
Form and Instruction	CMS-1572	Home Health Agency and Deficiencies Report	CMS 1572. 12.21.22.pdf		Yes	Yes	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	Previously Approved
Annual Number of Responses for this IC	3,833	3,833
Annual IC Time Burden (Hours)	1,917	1,917
Annual IC Cost Burden (Dollars)	142,778	142,778

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Crosswalk	Change Crosswalk for CMS-1572. 11.01.22.docx	01/27/2023
Compare version of CMS-1572	CMS.1572 form COMPARE VERSION. 01.26.23.docx	01/27/2023

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