View Information Collection Request (ICR) Package
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Please note that the OMB number and expiration date may not have been determined when this Information Collection Request and associated Information Collection forms were submitted to OMB. The approved OMB number and expiration date may be found by clicking on the Notice of Action link below.
View ICR - OIRA Conclusion
OMB Control No:
0938-0074
ICR Reference No:
201808-0938-008
Status:
Historical Active
Previous ICR Reference No:
201803-0938-005
Agency/Subagency:
HHS/CMS
Agency Tracking No:
CCSQ
Title:
(CMS-29) Request for Certification as Rural Health Clinic Form and Supporting Regulations
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:
09/10/2018
Retrieve Notice of Action (NOA)
Date Received in OIRA:
08/17/2018
Terms of Clearance:
Inventory as of this Action
Requested
Previously Approved
Expiration Date
09/30/2021
36 Months From Approved
09/30/2018
Responses
5,082
0
900
Time Burden (Hours)
801
0
150
Cost Burden (Dollars)
812
0
0
Abstract:
The Form CMS-29 is utilized as an application to be completed by suppliers of RHC services requesting participation in the Medicare/Medicaid programs. This form initiates the process of obtaining a decision as to whether the conditions for certification are met as a supplier of RHC services. It also promotes data reduction or introduction to and retrieval from the Automated Survey Process Environment (ASPEN) and related survey and certification databases by the CMS Regional Offices.
Authorizing Statute(s):
Statute at Large:
17 Stat. 1864
Statute at Large:
17 Stat. 1875
Citations for New Statutory Requirements:
None
Associated Rulemaking Information
RIN:
Stage of Rulemaking:
Federal Register Citation:
Date:
Not associated with rulemaking
Federal Register Notices & Comments
60-day Notice:
Federal Register Citation:
Citation Date:
83 FR 1037
01/09/2018
30-day Notice:
Federal Register Citation:
Citation Date:
83 FR 11753
03/16/2018
Did the Agency receive public comments on this ICR?
No
Number of Information Collection (IC) in this ICR:
7
IC Title
Form No.
Form Name
Completion of the Survey CMS-29 Form for state survey agency triennial survey
Completion of the initial CMS-29 Form -new RHCs applying to participate in Medicare Program
CMS-29
Verification of Clinic Data - Rural Health Clinic Program
Medical Secretary to complete mailing for all RHCs surveyed
Medical Secretary to compulete survey task -RHCs being surveyed
New RHCs review the statutory and regulatory law
Photocopying of CMS-29 and filing by a Medical Secretary
Preparation for and mailing of the CMS-29 Form to the State agencies
ICR Summary of Burden
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
5,082
900
0
0
4,182
0
Annual Time Burden (Hours)
801
150
0
0
651
0
Annual Cost Burden (Dollars)
812
0
0
0
812
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:
It is important to note that the burden estimates stated in this PRA package have increased significantly (150 hours to 801 hours) from the burden estimates stated in the previous PRA package submission. This increase in burden is due to several factors. However, this revised burden estimate contains only that burden which is currently and has always been associated with the completion and handling of the initial and survey CMS-29 forms. We have not created nor added any new or additional burden related to the completion of the CMS-29 form that did not previously exist.
Annual Cost to Federal Government:
$4,849
Does this IC contain surveys, censuses, or employ statistical methods?
No
Does this ICR request any personally identifiable information (see
OMB Circular No. A-130
for an explanation of this term)? Please consult with your agency's privacy program when making this determination.
No
Does this ICR include a form that requires a Privacy Act Statement (see
5 U.S.C. §552a(e)(3)
)? Please consult with your agency's privacy program when making this determination.
No
Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]?
No
Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]?
No
Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)?
No
Is this ICR related to the Pandemic Response?
Uncollected
Agency Contact:
Denise King 410 786-1013 Denise.King@cms.hhs.gov
Common Form ICR:
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:
(a) It is necessary for the proper performance of agency functions;
(b) It avoids unnecessary duplication;
(c) It reduces burden on small entities;
(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;
(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;
(f) It indicates the retention periods for recordkeeping requirements;
(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:
(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;
(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.
(i) It uses effective and efficient statistical survey methodology (if applicable); and
(j) It makes appropriate use of information technology.
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.
Certification Date:
08/17/2018
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