[Federal Register Volume 69, Number 115 (Wednesday, June 16, 2004)]
[Notices]
[Page 33643]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 04-13506]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare and Medicaid Services

[Document Identifier: CMS-R-235, CMS-724 and CMS-R-297]


Agency Information Collection Activities: Submission for OMB 
Review; Comment Request

AGENCY: Centers for Medicare and Medicaid Services, HHS.
    In compliance with the requirement of section 3506(c)(2)(A) of the 
Paperwork Reduction Act of 1995, the Centers for Medicare and Medicaid 
Services (CMS) (formerly known as the Health Care Financing 
Administration (HCFA), Department of Health and Human Services, is 
publishing the following summary of proposed collections for public 
comment. Interested persons are invited to send comments regarding this 
burden estimate or any other aspect of this collection of information, 
including any of the following subjects: (1) The necessity and utility 
of the proposed information collection for the proper performance of 
the agency's functions; (2) the accuracy of the estimated burden; (3) 
ways to enhance the quality, utility, and clarity of the information to 
be collected; and (4) the use of automated collection techniques or 
other forms of information technology to minimize the information 
collection burden.
    1. Type of Information Collection Request: Extension of a currently 
approved collection; Title of Information Collection: Data Use 
Agreement Information Collection Requirements, model language, and 
supporting regulations in 45 CFR Section 5b.; Form No.: CMS-R-235 
(OMB 0938-0734); Use: Binding agreement stating conditions 
under which CMS will disclose and user will maintain CMS data that are 
protected by the Privacy Act.; Frequency: On occasion; Affected Public: 
Not-for-profit institutions; Number of Respondents: 1,500; Total Annual 
Responses: 1,500; Total Annual Hours: 750.
    2. Type of Information Collection Request: Extension of a currently 
approved collection; Title of Information Collection: The Medicare/
Medicaid Psychiatric Hospital Survey Data Contained in 42 CFR and 
supporting regulations in 42 CFR 482.60, 482.61, and 482.62.; Form No.: 
CMS-724 (OMB 0938-0378); Use: The collection of this data will 
assure an accurate data base for program planning and evaluation, and 
survey team composition for surveys of psychiatric hospitals. All 
freestanding psychiatric hospitals surveyed will be required to 
respond. Frequency: Annually; Affected Public: Federal Government, 
Business or other for-profit, Not-for-profit institutions, and State, 
local and tribal government; Number of Respondents: 200; Total Annual 
Responses: 200; Total Annual Hours: 100.
    3. Type of Information Collection Request: Extension of a currently 
approved collection; Title of Information Collection: Request for 
Employment Information; Form No.: CMS-R-297 (OMB 0938-0787); 
Use: This information is needed to determine whether a beneficiary can 
enroll in Part B under Section 1837(i) of the Act and/or qualify for a 
reduction in the premium amount under Section 1839(b) of the Act.; 
Frequency: On occasion; Affected Public: Business or other for-profit; 
Number of Respondents: 5000; Total Annual Responses: 5000; Total Annual 
Hours: 1250.
    To obtain copies of the supporting statement and any related forms 
for the proposed paperwork collections referenced above, access CMS Web 
site address at http://www.cms.hhs.gov/regulations/pra/, or E-mail your 
request, including your address, phone number, OMB number, and CMS 
document identifier, to [email protected], or call the Reports 
Clearance Office on (410) 786-1326. Written comments and 
recommendations for the proposed information collections must be mailed 
within 30 days of this notice directly to the OMB desk officer: OMB 
Human Resources and Housing Branch, Attention: Brenda Aguilar, New 
Executive Office Building, Room 10235, Washington, DC 20503.

    Dated: June 8, 2004.
John P. Burke, III,
Paperwork Reduction Act Team Leader, CMS Reports Clearance Officer, 
Office of Strategic Operations and Regulatory Affairs, Division of 
Regulations Development and Issuances.
[FR Doc. 04-13506 Filed 6-15-04; 8:45 am]
BILLING CODE 4120-03-P