OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

Home Health Agency Survey and Deficiencies Report, Home Health Functional Assessment Instrument

ICR 199602-0938-001 · OMB 0938-0355 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
IC IDCollectionTypeStatusForm
7987 Home Health Agency Survey and Deficiencies Report, Home Health Functional Assessment Instrument Form Migrated
ICR Details
0938-0355 199602-0938-001
Historical Active 199403-0938-004
HHS/CMS
Home Health Agency Survey and Deficiencies Report, Home Health Functional Assessment Instrument
Reinstatement without change of a previously approved collection   No
Regular
Approved without change 04/01/1996
Retrieve Notice of Action (NOA) 02/01/1996
Approved for use through 3/99 under the condition that HCFA incorporates the disclosures required by the Paperwork Reduction Act of 1995 and the implementing regulations at 5 CFR 1320. The revised forms including these dislosures should be submitted for the public docket.
  Inventory as of this Action Requested Previously Approved
04/30/1999 04/30/1999
17,244 0 0
129,330 0 0
0 0 0
In order to participate in the Medicare program as an HHA provider, the HHA must meet Federal standards. These forms are used to record information about patients' health and provider compliance with requirement and report information to the Federal Government.
None
None
No
1
IC Title Form No. Form Name
Home Health Agency Survey and Deficiencies Report, Home Health Functional Assessment Instrument HCFA-1572, HCFA-1515
  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 17,244 0 0 17,244 0 0
Annual Time Burden (Hours) 129,330 0 0 129,330 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
No
$0
Yes Part B of Supporting Statement
No
Uncollected
Uncollected
Uncollected
Uncollected
  No
On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
02/01/1996