View Information Collection (IC)

View Information Collection (IC)

IC Title:	Home Health Agency Survey and Deficiencies Report	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 and Instruction	CMS-1572	Home Health Agency And Deficiences Report	CMS 1572. 12.19.22.docx		No		Fillable Fileable
Form and Instruction	CMS-1572	Home Health Agency and Deficiencies Report	CMS 1572. 12.21.22.pdf		Yes	Yes	Fillable Fileable

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: 3,833	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	3,833	0	0	0	0	3,833
Annual IC Time Burden (Hours)	1,917	0	0	0	0	1,917
Annual IC Cost Burden (Dollars)	142,778	0	0	0	0	142,778

Documents for IC

Title	Document	Date Uploaded
Crosswalk	Change Crosswalk for CMS-1572. 11.01.22.docx	01/27/2023
Compare version of CMS-1572	CMS.1572 form COMPARE VERSION. 01.26.23.docx	01/27/2023

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