View Information Collection Request (ICR) Package

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View ICR - OIRA Conclusion

OMB Control No: 0938-0379	ICR Reference No: 201509-0938-007
Status: Historical Active	Previous ICR Reference No: 201207-0938-003
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Hospice Survey and Deficiencies Report Form (CMS-643)
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR: No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 04/28/2016
	Date Received in OIRA: 09/10/2015
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2019	36 Months From Approved	04/30/2016
Responses	1,325	0	1,217
Time Burden (Hours)	1,325	0	1,217
Cost Burden (Dollars)	0	0	0

ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to Agency Discretion
Annual Number of Responses	1,325	1,217	108
Annual Time Burden (Hours)	1,325	1,217	108
Annual Cost Burden (Dollars)	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: While there are no program changes, the burden has increased as a result of the increased number of hospice providers (3,377 in 2009 3,644 in 2012, and 3,976 in 2014).

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