Home and Community Based Services (HCBS) Incident Management Survey (CMS-10692)

Forms and Documents

Document Name	Status
Form CMS-10692 HCBS Incident Management Survey Form and Instruction	New
Incident Management Survey - Public Comment Response.pdf Supplementary Document	2019-03-15
CMS-10692 - Supporting Statement B (version 1).doc Supporting Statement B	2019-03-15
CMS-10692 - Supporting Statement A (version 2).docx Supporting Statement A	2019-03-15

IC Document Collections

IC ID	Document Title	Status
235360	HCBS Incident Management Survey Form and Instruction	New

ICR Details

OMB Control No: 0938-1362	ICR Reference No: 201903-0938-008
Status: Active	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No: CMCS
Title: Home and Community Based Services (HCBS) Incident Management Survey (CMS-10692)
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 06/13/2019
	Date Received in OIRA: 03/15/2019
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2022	36 Months From Approved
Responses	102	0	0
Time Burden (Hours)	153	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: States will be requested to complete and submit the survey which is intended to identify methods and promising practices for identifying, reporting, tracking, and resolving incidents of abuse, neglect, and exploitation. The results of the survey will also be used to review the strengths and weaknesses of each state’s incident management system and will inform guidance to help ensure states comply with sections 1902(a)(30)(A) and 1915(c)(2)(A) of the Social Security Act.

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Authorizing Statute(s): US Code: 42 USC 1915(c)(2)(A) Name of Law: Social Security Act
  

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:
	83 FR 64346	12/14/2018
30-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 9527	03/15/2019
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
HCBS Incident Management Survey	CMS-10692	HCBS Incident Management Survey

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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	102	0	0	102	0	0
Annual Time Burden (Hours)	153	0	0	153	0	0
Annual Cost Burden (Dollars)	0	0	0	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: Not applicable. This is a new submission

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Annual Cost to Federal Government: $192,705

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

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

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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: 03/15/2019

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