View Information Collection Request (ICR) Package

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View ICR - OIRA Conclusion

OMB Control No: 0938-0379	ICR Reference No: 201907-0938-005
Status: Historical Active	Previous ICR Reference No: 201509-0938-007
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Hospice Survey and Deficiencies Report Form (CMS-643)
Type of Information Collection: Reinstatement without change of a previously approved collection	Common Form ICR: No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 09/19/2019
	Date Received in OIRA: 08/13/2019
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2022	36 Months From Approved
Responses	1,600	0	0
Time Burden (Hours)	1,600	0	0
Cost Burden (Dollars)	0	0	0

ICR Summary of Burden

	Total Approved	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	1,600	275	1,325
Annual Time Burden (Hours)	1,600	275	1,325
Annual Cost Burden (Dollars)	0	0	0

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

Burden Increase Due to:

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 (4,281 in 2014, 4,625 in 2016, and 4801 in 2018). The burden hours have increased from 1,325 to 1,600.

Annual Cost to Federal Government: $0

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

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