Home Health Agency Survey and Deficiencies Report, Home Health Functional Assessment Instrument and Supporting Regulations in 42 CFR 488.26 and 442.30

Home Health Agency Survey and Deficiencies Report, Home Health Functional Assessment Instrument and Supporting Regulations in 42 CFR 488.26 and 442.30 (CMS-1515 & 1572)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0355 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-1515A Home Health Agency Survey and Deficiencies Report, Home Health Functional Assessment Instrument and Supporting Regulations in 42 CFR 488.26 and 442.30 Form
CMS-1515A Home Health Functional Assessment Instrument Module A CMS-1515A.pdf Form
CMS-1515B Home Health Functional Assessment Instrument: Module B CMS-1515B.pdf Form
CMS-1515C Home Health Functional Assessment: Module C: Home Visit CMS-1515C.pdf Form
CMS-1515D Home Health Functional Assessment Patient Function and C CMS-1515D.pdf Form
CMS-1515E Home Health Function and Care Summary: Module D CMS-1515E.pdf Form
CMS-1515F Calendar Worksheet - Prescribed Visits CMS-1515F.pdf Form
CMS-1572 Home Health Agency Survey and Deficiencies Report 508CMS-1572.pdf Form

Information Collection (IC) Details

IC Title:	Home Health Agency Survey and Deficiencies Report, Home Health Functional Assessment Instrument and Supporting Regulations in 42 CFR 488.26 and 442.30	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 488.26 42 CFR 442.30

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-1515A	Home Health Functional Assessment Instrument Module A	CMS-1515A.pdf	No	No	Paper Only
Form	CMS-1515B	Home Health Functional Assessment Instrument: Module B	CMS-1515B.pdf	No	No	Paper Only
Form	CMS-1515C	Home Health Functional Assessment: Module C: Home Visit	CMS-1515C.pdf	No	No	Paper Only
Form	CMS-1515D	Home Health Functional Assessment Patient Function and Care Summary: Module D	CMS-1515D.pdf	No	No	Paper Only
Form	CMS-1515E	Home Health Function and Care Summary: Module D	CMS-1515E.pdf	No	No	Paper Only
Form	CMS-1515F	Calendar Worksheet - Prescribed Visits	CMS-1515F.pdf	No	No	Paper Only
Form	CMS-1572	Home Health Agency Survey and Deficiencies Report	508CMS-1572.pdf	No	No	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 5,614	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	5,614	-3,131	8,745
Annual IC Time Burden (Hours)	9,825	5,452	4,373
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.