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 488.26 and 442.30 (CMS-1515 & 1572)

ICR 201001-0938-008 · OMB 0938-0355 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
Form CMS-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 Modified Repair queued
2009CMS-1572 CMS-1572 supporting statement.DOC Supporting Statement A Uploaded 2009-12-04 Available
IC Document Collections
IC IDCollectionTypeStatusForm
7990 Home Health Agency Survey and Deficiencies Report, Home Health Functional Assessment Instrument and Supporting Regulations in 42 CFR 488.26 and 442.30 Form Modified
ICR Details
0938-0355 201001-0938-008
Historical Active 200611-0938-013
HHS/CMS
Home Health Agency Survey and Deficiencies Report, Home Health Functional Assessment Instrument and Supporting Regulations in 42 CFR 488.26 and 442.30 (CMS-1515 & 1572)
Extension without change of a currently approved collection   No
Regular
Approved without change 02/26/2010
Retrieve Notice of Action (NOA) 01/27/2010
  Inventory as of this Action Requested Previously Approved
02/28/2013 36 Months From Approved 02/28/2010
5,614 0 8,745
9,825 0 4,373
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.
US Code: 42 USC 442.30 Name of Law: Agreement as Evidence of Certification
   US Code: 42 USC 488.26 Name of Law: Determining Compliance
  
None
Not associated with rulemaking
  74 FR 44366 08/28/2009
74 FR 62575 11/30/2009
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 5,614 8,745 0 0 -3,131 0
Annual Time Burden (Hours) 9,825 4,373 0 0 5,452 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No
$0
No
No
Uncollected
Uncollected
No
Uncollected
Melissa Musotto 4107866962
  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.
01/27/2010