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Agenda
Reg Review
ICR
Information Collection List
IC Title
Status
Responses
Hours
Dollars
Document Type
Form No.
Form Name
Home Health Agency Survey and Deficiencies Report, Home Health Functional Assessment Instrument and Supporting Regulations in 42 CFR 488.26 and 442.30
Modified
8745
4373
0
Form
1515a
Home Health Functional Assessment Instrument: Module A
Form
1515b
Home Health Functional Assessment Instrument: Module B
Form
1515e
Home Health Function and Care Summary: Module E
Form
1515c
Home Health Functional Assessment: Module C
Form
1515d
Home Health Functional Assessment Patient Function and Care Summary: Module D
Form
1515F
Calendar Worksheet
Form
1572(a-e)
Home Health Agency Survey and Deficiencies Report
Total burden requested under this ICR:
8745
4373
0
To view an IC, click on IC Title