Request for Certification as Supplier of Portable X-Ray and Portable X-Ray Survey Report Form (CMS-1880 and 1882)

Forms and Documents

Document Name	Status
Form CMS-1880 Request for Certification as Supplier of Portable X-Ray and Portable X-Ray Survey Report Form Form and Instruction	Modified
CMS-1882 Crosswalk_2014.pdf Supplementary Document	2014-05-07
CMS-1882 Change Statement.pdf Justification for No Material/Nonsubstantive Change	2014-05-07
CMS-1880 and -1882 Response to Comments Final Draft including OSORA Comments 03-05-2012 GJ].doc Supplementary Document	2012-03-08
CMS-1880 and -1882 Supporting Statement part A [rev 03-12-2012].docx Supporting Statement A	2012-03-13

IC Document Collections

IC ID	Document Title	Status
7777	Request for Certification as Supplier of Portable X-Ray and Portable X-Ray Survey Report Form Form and Instruction	Modified

ICR Details

OMB Control No: 0938-0027	ICR Reference No: 201405-0938-002
Status: Historical Active	Previous ICR Reference No: 201203-0938-006
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Request for Certification as Supplier of Portable X-Ray and Portable X-Ray Survey Report Form (CMS-1880 and 1882)
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 09/28/2014
	Date Received in OIRA: 05/13/2014
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2015	06/30/2015	06/30/2015
Responses	86	0	86
Time Burden (Hours)	151	0	151
Cost Burden (Dollars)	0	0	0

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Abstract: The Medicare program requires portable X-ray suppliers to be surveyed for health and safety standards. The CMS-1882 is the survey form that records survey results. The CMS-1880 is used by the surveyor to determine if a portable X-ray applicant meets the eligibility requirements.

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Authorizing Statute(s): Statute at Large: 18 Stat. 1861 Name of Statute: null
   Statute at Large: 18 Stat. 1864 Name of Statute: null
   Statute at Large: 18 Stat. 1875 Name of Statute: null
   US Code: 42 USC 486.100 Name of Law: Conditions for Coverage: Portable X-ray Services
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 80372	12/23/2011
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 14806	03/13/2012
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Request for Certification as Supplier of Portable X-Ray and Portable X-Ray Survey Report Form	CMS-1882, CMS-1880	Request for Certification as a Supplier of Portable X-ray Services ,   Portable X-ray Survey Report

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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	86	86	0	0	0	0
Annual Time Burden (Hours)	151	151	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	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:

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Annual Cost to Federal Government: $5,935

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? 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

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Common Form ICR:  No

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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: 05/13/2014

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