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Agenda
Reg Review
ICR
View Information Collection (IC)
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
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form
CMS-1515A
Home Health Functional Assessment Instrument Module A
CMS-1515A.pdf
No
No
Paper Only
Form
CMS-1515B
Home Health Functional Assessment Instrument: Module B
CMS-1515B.pdf
No
No
Paper Only
Form
CMS-1515C
Home Health Functional Assessment: Module C: Home Visit
CMS-1515C.pdf
No
No
Paper Only
Form
CMS-1515D
Home Health Functional Assessment Patient Function and Care Summary: Module D
CMS-1515D.pdf
No
No
Paper Only
Form
CMS-1515E
Home Health Function and Care Summary: Module D
CMS-1515E.pdf
No
No
Paper Only
Form
CMS-1515F
Calendar Worksheet - Prescribed Visits
CMS-1515F.pdf
No
No
Paper Only
Form
CMS-1572
Home Health Agency Survey and Deficiencies Report
508CMS-1572.pdf
No
No
Paper Only
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Health Care Services
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
5,614
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
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
5,614
0
0
-3,131
0
8,745
Annual IC Time Burden (Hours)
9,825
0
0
5,452
0
4,373
Annual IC Cost Burden (Dollars)
0
0
0
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.