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Federal forms, ICRs, and supporting documents

Information Collection Request

Home Health Agency Survey and Deficiencies Report, Home Health Functional Assessment Instrument and Supporting Regulations in 42 CFR Part 484.10 and 42 CFR Part 484.52

ICR 199812-0938-003 · 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
7988 Home Health Agency Survey and Deficiencies Report, Home Health Functional Assessment Instrument and Supporting Regulations in 42 CFR Part 484.10 and 42 CFR Part 484.52 Form Migrated
ICR Details
0938-0355 199812-0938-003
Historical Active 199602-0938-001
HHS/CMS
Home Health Agency Survey and Deficiencies Report, Home Health Functional Assessment Instrument and Supporting Regulations in 42 CFR Part 484.10 and 42 CFR Part 484.52
Revision of a currently approved collection   No
Regular
Approved without change 01/28/1999
Retrieve Notice of Action (NOA) 12/08/1998
Approved for use through 1/2002 under the same conditions dated 4/1/96.
  Inventory as of this Action Requested Previously Approved
02/28/2002 02/28/2002 04/30/1999
19,884 0 17,244
19,884 0 129,330
0 0 0
In order to participate in the Medicare program as a Home Health Agency (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
  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 19,884 17,244 0 2,640 0 0
Annual Time Burden (Hours) 19,884 129,330 0 -109,446 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
Yes
$0
No
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.
12/08/1998