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

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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​regulations/​pra/​, or E-mail your request, including your address, phone number, OMB number, and CMS document identifier, to, 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.

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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.

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[FR Doc. 04-13506 Filed 6-15-04; 8:45 am]