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

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Centers for Medicare & 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 & Medicaid Services (CMS), 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 function; (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: Revision of a currently approved collection; Title of Information Collection: Request for Certification as a Rural Health Clinic Form and Supporting Regulations in 42 CFR 491.1-491.11; Use: The Form CMS-29, Request for Certification as a Supplier of Rural Health Clinic (RHC) Services under the Medicare/Medicaid Program, is utilized as an application to be completed by suppliers of RHC services requesting participation in the Medicare program. This form initiates the process of obtaining a decision as to whether the conditions for certification are met as a supplier of RHC services. It also promotes data reduction or introduction to and retrieval from the Automated Survey Process Environment (ASPEN) and related survey and certification databases by the CMS Regional Offices. Should any question arise regarding the structure of the organization, this information is readily available. With this renewal request, the title of the Form CMS-29 is being revised to better describe the purpose of the data being collected. Both new and existing clinics must provide and attest to the accuracy of specific clinic data as a part of the RHC certification process. Therefore, the revised title is “Form CMS-29/Verification of Clinic Data—Rural Health Clinic Program.” The Form CMS-29 is also being revised to remove Section V, Federal Support. The information captured under Section V is not a deciding factor as to whether or not a clinic meets RHC certification requirements. Therefore, it is unnecessary to require facilities to complete this section as a part of the certification process; Form Number: CMS-29 (OCN 0938-0074); Frequency: Occasionally (initially and then every six years); Affected Public: Private Sector (Business or other for-profit and Not-for-profit institutions); Number of Respondents: 3,981; Total Annual Responses: 830; Total Annual Hours: 138. (For policy questions regarding this collection contact Shonté Carter at (410) 786-3532. For all other issues call (410) 786-1326.)

2. Type of Information Collection Request: New collection (request for new OMB control number); Title of Information Collection: Nursing Home Quality Improvement Questionnaire; Use: The information obtained via the Nursing Home Quality Improvement Questionnaire will be utilized by CMS staff in the Survey & Certification Group, Division of Nursing Homes, to identify areas for quality assurance and performance improvement (QAPI) technical assistance (TA) that will be useful to nursing facilities as they prepare to meet the new QAPI regulation that was mandated as part of the Affordable Care Act. Specifically, the information collected through the use of the questionnaire will be used to establish a baseline of QAPI practices in nursing homes, gather information on the challenges and barriers to implementing effective QAPI programs, assess the development of QAPI systems, determine what types of TA to make available to nursing homes, and assess the potential impact of TA in advancing QAPI in nursing homes; Form Number: CMS-10366 (OCN 0938-New); Frequency: Once; Affected Public: Private Sector (Business or other for-profits and Not-for-profit institutions) and State, Local or Tribal Governments; Number of Respondents: 4,200; Total Annual Responses: 4,200; Total Annual Hours: 1,386. (For policy questions regarding this collection contact Debra Lyons at (410) 786-6780. For all other issues call (410) 786-1326.)

To obtain copies of the supporting statement and any related forms for the proposed paperwork collections referenced above, access CMS Web Site address at, or Email your request, including your address, phone number, OMB number, and CMS document identifier, to, or call the Reports Clearance Office on (410) 786-1326.

To be assured consideration, comments and recommendations for the proposed information collections must be received by the OMB desk officer at the address below, no later than 5 p.m. on March 8, 2012. OMB, Office of Information and Regulatory Affairs, Attention: CMS Desk Officer. Fax Number: (202) 395-6974. Email:

Dated: January 31, 2012.

Martique Jones,

Director, Regulations Development Group, Division-B, Office of Strategic Operations and Regulatory Affairs.

[FR Doc. 2012-2762 Filed 2-6-12; 8:45 am]