Information Collection

Home Health Agency Survey and Deficiencies Report, Home Health Functional Assessment Instrument and Supporting Regulations in 42 CFR 488.26 and 442.30

IC 7990 under ICR 200611-0938-013 · OMB 0938-0355.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0355 can be found here:

Documents and Forms

Document Name Document Type
Form 1515a Home Health Agency Survey and Deficiencies Report, Home Health Functional Assessment Instrument and Supporting Regulations in 42 CFR 488.26 and 442.30 Form
1515a Home Health Functional Assessment Instrument: Module A cms1515a.pdf Form
1515b Home Health Functional Assessment Instrument: Module B cms1515b.pdf Form
1515e Home Health Function and Care Summary: Module E cms1515e.pdf Form
1515c Home Health Functional Assessment: Module C cms1515c.pdf Form
1515d Home Health Functional Assessment Patient Function and C cms1515d.pdf Form
1515F Calendar Worksheet cms1515f.pdf Form
1572(a-e) Home Health Agency Survey and Deficiencies Report cms1572a-e.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Home Health Agency Survey and Deficiencies Report, Home Health Functional Assessment Instrument and Supporting Regulations in 42 CFR 488.26 and 442.30	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 488.26 42 CFR 442.30

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	1515a	Home Health Functional Assessment Instrument: Module A	cms1515a.pdf	No	No	Paper Only
Form	1515b	Home Health Functional Assessment Instrument: Module B	cms1515b.pdf	No	No	Paper Only
Form	1515e	Home Health Function and Care Summary: Module E	cms1515e.pdf	No	No	Paper Only
Form	1515c	Home Health Functional Assessment: Module C	cms1515c.pdf	No	No	Paper Only
Form	1515d	Home Health Functional Assessment Patient Function and Care Summary: Module D	cms1515d.pdf	No	No	Paper Only
Form	1515F	Calendar Worksheet	cms1515f.pdf	No	No	Paper Only
Form	1572(a-e)	Home Health Agency Survey and Deficiencies Report	cms1572a-e.pdf	No	No	Paper Only

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 8,745	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	8,745	-15,405	24,150
Annual IC Time Burden (Hours)	4,373	509	3,864
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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