Information Collection

Home Health Agency (hha) Medicare And Medicaid Survey Report, Forms For Hha Conditions Of Participation

IC 113510 under ICR 199403-0938-004 · OMB 0938-0355.

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Documents and Forms

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Information Collection (IC) Details

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IC Title:	HOME HEALTH AGENCY (HHA) MEDICARE AND MEDICAID SURVEY REPORT, FORMS FOR HHA CONDITIONS OF PARTICIPATION	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Migrated

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?
Form	HCFA-1515	No	No
Form	1572, 36 U3	No	No
Form	36 SP	No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 6,900	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	6,900	6,900
Annual IC Time Burden (Hours)	103,500	103,500
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded

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