Information Collection

Hospice Survey and Deficiencies Report Form (CMS-643)

IC 8022 under ICR 202607-0938-007 · OMB 0938-0379.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-643 Hospice Survey and Deficiencies Report Hospice Survey and Deficiencies Report Form (CMS-643)	Form
CMS-643 Hospice Survey and Deficiencies Report CMS 643 (fillable 2026).pdf	Form
Change Crosswalk for CMS643 Form.pdf Crosswalk	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

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	CMS-643				Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,343

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	2,343	292	2,051
Annual IC Time Burden (Hours)	1,172	-48,052	49,224
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Crosswalk		07/20/2026

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

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