Information Collection

HOPE and HUV Timepoint

IC 269622 under ICR 202409-0938-004 · OMB 0938-1153.

Documents and Forms

Document Name Document Type
Form CMS-10390 HOPE and HUV Timepoint Form
CMS-10390 Hospice Outcome and Patient Evaluation HOPE v1.00_All Item_508c.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	HOPE and HUV Timepoint	Agency IC Tracking Number:	10390

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10390	Hospice Outcome and Patient Evaluation	HOPE v1.00_All Item_508c.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 5,640	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	2,763,600	2,763,600
Annual IC Time Burden (Hours)	2,487,465	2,487,465
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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