OMB.report

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 - 42 CFR Part 484.52

ICR 200201-0938-001 · 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
7989 Home Health Agency survey and Deficiencies Report, Home Health Functional Assessment Instrument and Supporting Regulations in 42 CFR Part 484.10 - 42 CFR Part 484.52 Form Migrated
ICR Details
0938-0355 200201-0938-001
Historical Active 199812-0938-003
HHS/CMS
Home Health Agency survey and Deficiencies Report, Home Health Functional Assessment Instrument and Supporting Regulations in 42 CFR Part 484.10 - 42 CFR Part 484.52
Extension without change of a currently approved collection   No
Regular
Approved without change 03/01/2002
Retrieve Notice of Action (NOA) 01/04/2002
Approved for use through 9/2003 under the conditions that CMS: 1) immediately deletes the OMB address from the PRA disclosure statements; and 2) evaluates opportunities for integrating these survey collections with the OASIS and reducing overall burden on the HHA industry while maintaining/enhancing benefici- ary quality of care.
  Inventory as of this Action Requested Previously Approved
11/30/2003 11/30/2003 02/28/2002
13,994 0 19,884
19,884 0 19,884
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 13,994 19,884 0 -5,890 0 0
Annual Time Burden (Hours) 19,884 19,884 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
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.
01/04/2002