38202 Federal Register / Vol. 74, No. 146 / Friday, July 31, 2009 / Notices 

9With the exception of the MSSC–R, respondents only complete Service Experience Study measures at follow-up points. See Footnote #3 for 

the explanation about the average number of responses per respondent. 10Approximate number of children/families in each sector, for the Sector and Comparison Study. This includes cases within the communities, 

as well as within the comparison sample. 11For each community, 1 respondent will be a caregiver and 3 respondents will be administrators/providers. 12Assumes that each community will use flexible funds expenditures on average for approximately one quarter of the children/youth enrolled. 13Assumes that three expenditures, on average, will be spent on each child/youth receiving flexible fund benefits. 14Assumes that each child/youth in system of care communities and in the comparison sample will have 100 service episodes, on average. 

Written comments and 

recommendations concerning the 

proposed information collection should 

be sent by August 28, 2009 to: SAMHSA 

Desk Officer, Human Resources and 

Housing Branch, Office of Management 

and Budget, New Executive Office 

Building, Room 10235, Washington, DC 

20503; due to potential delays in OMB’s 

receipt and processing of mail sent 

through the U.S. Postal Service, 

respondents are encouraged to submit 

comments by fax to: 202–395–6974. 

Dated: July 27, 2009. 

Elaine Parry, 

Director, Office of Program Services. 

[FR Doc. E9–18317 Filed 7–30–09; 8:45 am] 

BILLING CODE 4162–20–P 

DEPARTMENT OF HEALTH AND 

HUMAN SERVICES 

Substance Abuse and Mental Health 

Services Administration 

Agency Information Collection 

Activities: Submission for OMB 

Review; Comment Request 

Periodically, the Substance Abuse and 

Mental Health Services Administration 

(SAMHSA) will publish a summary of 

information collection requests under 

OMB review, in compliance with the 

Paperwork Reduction Act (44 U.S.C. 

Chapter 35). To request a copy of these 

documents, call the SAMHSA Reports 

Clearance Officer on (240) 276–1243. 

Project: National Evaluation of the 

Comprehensive Community Mental 

Health Services for Children and Their 

Families Program: Phase V (OMB No. 

0930–0280)—Revision 

The Substance Abuse and Mental 

Health Services Administration 

(SAMHSA) Center for Mental Health 

Services (CMHS) is responsible for the 

National Evaluation of the 

Comprehensive Community Mental 

Health Services for Children and Their 

Families Program, which collects data 

on child mental health outcomes, family 

life, and service system development 

and performance. Data will be collected 

on 30 service systems and roughly 8,810 

children and families. 

The data collection for this evaluation 

will be conducted for a 3-year period. 

The core of service system data will be 

collected twice (every 18 to 24 months) 

during the 3-year evaluation period. A 

sustainability survey will be conducted 

in selected years. Service delivery and 

system variables of interest include the 

following: Maturity of system of care 

development; adherence to the system 

of care program model; services 

received by youth and their families, 

and the costs of those services; and 

consumer service experience. 

The length of time that individual 

families will participate in the study 

ranges from 18 to 36 months depending 

on when they enter the evaluation. 

Child and family outcomes of interest 

will be collected at intake and during 

subsequent follow-up interviews at sixmonth intervals. Client service 

experience information is collected at 

these follow-up interviews. Measures 

included in an outcome interview are 

determined by the type of assessment 

(intake or follow-up), child’s age, and 

whether the respondent is the caregiver 

or a youth. 

The outcome measures include the 

following: Child symptomatology and 

functioning, family functioning, 

material resources, and caregiver strain. 

The caregiver interview package 

includes the Caregiver Information 

Questionnaire, Child Behavior 

Checklist, Behavioral and Emotional 

Rating Scale (BERS), Education 

Questionnaire, Columbia Impairment 

Questionnaire, Living Situations 

Questionnaire, Family Life 

Questionnaire, and Caregiver Strain 

Questionnaire at intake, and also 

includes the Multi-service Sector 

Contacts Form, Cultural Competence 

and Service Provision Questionnaire 

and the Youth Services Survey (a 

national outcome measurement tool) at 

follow-up assessments. Caregivers of 

children under age 6 complete the 

Vineland Screener to assess 

development, and do not complete the 

BERS. The Youth Interview package 

includes the Youth Information 

Questionnaire, Revised Children’s 

Manifest Anxiety Scale, Reynolds 

Depression Scale, BERS (youth version), 

Delinquency Survey, Substance Use 

Survey, GAIN-Quick: Substance 

Dependence Scale, and Youth Services 

Survey (youth version). 

The evaluation also includes three 

special studies: (1) An evidence-based 

practices study that examines the effects 

of various factors on the implementation 

and use of evidence-based treatments 

and approaches in system of care 

communities; (2) A cultural and 

linguistic competence study that 

examines the extent to which the 

cultural and linguistic characteristics of 

communities influence program 

implementation and provider 

adaptation of evidence-based 

treatments, and provider service 

delivery decisions based on provider 

culture and language; and (3) an 

evaluation of the communities’ use of 

reports produced by the national 

evaluation for continuous quality 

improvement. The national evaluation 

measures address the national outcome 

measures for mental health programs as 

currently established by SAMHSA. 

Table 1 summarizes which national 

evaluation components are unchanged 

from the original 2006 submission and 

which are new or changed. 

TABLE 1—STUDY COMPONENT AND INSTRUMENT REVISIONS FOR PHASE V RE-SUBMISSION

New or changed 

for 2009 

resubmission 

No change Nature of change 

System of Care Assessment 

Site Visit Tables ........................................................ ............................ X 

Interview Protocols ................................................... ............................ X 

Inter-Agency Collaboration Scale (IACS) ................. ............................ X 


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Federal Register / Vol. 74, No. 146 / Friday, July 31, 2009 / Notices 38203 

TABLE 1—STUDY COMPONENT AND INSTRUMENT REVISIONS FOR PHASE V RE-SUBMISSION—Continued 

New or changed 

for 2009 

resubmission 

No change Nature of change 

Longitudinal Child and Family Outcome Study 

Caregiver Information Questionnaire (CIQ–I) ........... X ............................ Question 39a skip pattern revised. 

Question 39d list of medications updated. 

Caregiver Information Questionnaire (CIQ–F) ......... X ............................ Question 39a skip pattern revised. 

Question 39d list of medications updated. 

Caregiver Strain Questionnaire (CGSQ) .................. ............................ X 

Child Behavior Checklist (CBCL)/Child Behavior 

Checklist 11⁄2–5 (CBCL 11⁄2–5).

............................ X 

Education Questionnaire—Revised (EQ–R) ............ X ............................ Slight wording change to interviewer note and the 

term ‘‘day care’’ changed to ‘‘childcare.’’ 

Living Situations Questionnaire (LSQ) ..................... ............................ X 

Family Life Questionnaire (FLQ) .............................. ............................ X 

Behavioral and Emotional Rating Scale—Second 

Edition—Parent Rating Scale (BERS–2C).

............................ X 

Columbia Impairment Scale (CIS) ............................ ............................ X 

Vineland Screener (VS) ............................................ ............................ X 

Delinquency Survey—Revised (DS–R) .................... ............................ X 

Behavioral and Emotional Rating Scale—Second 

Edition, Youth Rating Scale (BERS–2Y).

............................ X 

GAIN-Quick Substance Related Issues (GAIN 

Quick-R).

............................ X 

Substance Use Survey—Revised (SUS–R) ............. ............................ X 

Revised Children’s Manifest Anxiety Scales 

(RCMAS).

............................ X 

Reynolds Adolescent Depression Scale—Second 

Edition (RADS–2).

............................ X 

Youth Information Questionnaire (YIQ–I) ................. ............................ X 

Youth Information Questionnaire (YIQ–F) ................ ............................ X 

Service Experience Study 

Multi-Sector Service Contacts Questionnaire—Revised (MSSC–R).X ............................ Slight modification to Card 4, and Cards 6 and 7 

are new. 

Evidence-Based Practices Experience Measure 

(EBPEM).

............................ X 

Cultural Competence and Service Provision Questionnaire (CCSP)............................. X 

Youth Services Survey for Families (YSS–F) .......... ............................ X 

Youth Services Survey (YSS) .................................. ............................ X 

Services and Costs Study 

Flex Funds Data Dictionary ...................................... X ............................ New. 

Services and Costs Data Dictionary ......................... X ............................ New. 

Sustainability Study 

Sustainability Survey ................................................ ............................ X 

Continuous Quality Improvement (CQI) Initiative Evaluation 

CQI Initiative Survey ................................................. X ............................ New. 

CQI Initiative Interview Guide ................................... X ............................ New. 

Evidence-Based Practices Study 

System-level Implementation Factors Discussion 

Guide.

X ............................ New. 

Service-level Implementation Factors Discussion 

Guide.

X ............................ New. 

Consumer-level Implementation Factors Discussion 

Guide.

X ............................ New. 

Cultural and Linguistic Competence Study 

CCIOSAS—Beneficiaries of Self-Assessment Findings Focus Group Guide—Staff and Partners.X ............................ New. 

CCIOSAS—Beneficiaries of Self-Assessment Findings Focus Group Guide—Caregivers.X ............................ New. 


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38204 Federal Register / Vol. 74, No. 146 / Friday, July 31, 2009 / Notices 

TABLE 1—STUDY COMPONENT AND INSTRUMENT REVISIONS FOR PHASE V RE-SUBMISSION—Continued 

New or changed 

for 2009 

resubmission 

No change Nature of change 

CCIOSAS—Beneficiaries of Self-Assessment Findings Focus Group Guide—Youth.X ............................ New. 

CCIOSAS—Participants in Self-Assessments Focus 

Group Guide—Staff and Partners.

X ............................ New. 

CCIOSAS—Participants in Self-Assessments Focus 

Group Guide—Caregivers.

X ............................ New. 

CCIOSAS—Participants in Self-Assessments Focus 

Group Guide—Youth.

X ............................ New. 

CCIOSAS—Users of Self-Assessment Findings 

Focus Group Guide—Staff and Partners.

X ............................ New. 

CCIOSAS—Users of Self-Assessment Findings 

Focus Group Guide—Caregivers.

X ............................ New. 

CCIOSAS—Users of Self-Assessment Findings 

Focus Group Guide—Youth.

X ............................ New. 

CCIOSAS—Telephone Interview—Staff and Partners.X ............................ New. 

CCEBPS—Managers of EBP Process Focus Group 

Guide.

X ............................ New. 

CCEBPS—Providers of EBP Focus Group Guide ... X ............................ New. 

CCEBPS—Family Focus Group Guide .................... X ............................ New. 

CCEBPS—Youth Focus Group Guide ..................... X ............................ New. 

CCEBPS—Telephone Interview ............................... X ............................ New. 

Internet-based technology will be 

used for data entry and management, 

and for collecting data using Web-based 

surveys. The average annual respondent 

burden, with detail provided about 

burden contributed by specific 

measures, is estimated below. The 

estimate reflects the average number of 

respondents in each respondent 

category, the average number of 

responses per respondent per year, the 

average length of time it will take for 

each response, and the total average 

annual burden for each category of 

respondent and for all categories of 

respondents combined. 

TABLE 2—DETAILED ESTIMATE OF RESPONDENT BURDEN

[Note: Total burden is annualized over a 3-year period.] 

Instrument Respondent Number of 

respondents 

Total average 

number of 

responses per 

respondent 

Hours per 

response 

Total burden 

hours 

3-year average annual 

burden hours 

System of Care Assessment 

Interview Guides and Data Collection Forms.Key site informants.

1 630 1 1 .00 630 210 

Interagency Collaboration Scale 

(IACS).

Key site informants.630 1 0 .13 82 27 

Longitudinal Child and Family Outcome Study 

Caregiver Information Questionnaire 

(CIQ–IC).

Caregiver ............ 2 8,810 1 0 .283 2,493 831 

Caregiver Information Questionnaire 

Followup (CIQ–FC).

Caregiver ............ 8,810 3 2 0 .200 3,524 1,175 

Caregiver Strain Questionnaire 

(CGSQ).

Caregiver ............ 8,810 3 0 .167 4,414 1,471 

Child Behavior Checklist (CBCL)/ 

Child Behavior Checklist 11⁄2–5 

(CBCL 11⁄2–5).

Caregiver ............ 8,810 3 0 .333 8,801 2,934 

Education Questionnaire—Revised 

(EQ–R).

Caregiver ............ 8,810 3 0 .333 8,801 2,934 

Living Situations Questionnaire 

(LSQ).

Caregiver ............ 8,810 3 0 .083 2,194 731 

The Family Life Questionnaire (FLQ) Caregiver ............ 8,810 3 0 .050 1,322 441 

Behavioral and Emotional Rating 

Scale—Second Edition, Parent 

Rating Scale (BERS–2C).

Caregiver ............ 4 7,488 3 0 .167 4,193 1,398 

Columbia Impairment Scale (CIS) .... Caregiver ............ 5 8,369 3 0 .083 2,084 695 

The Vineland Screener (VS) ............ Caregiver ............ 6 1,321 3 0 .250 330 110 


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Federal Register / Vol. 74, No. 146 / Friday, July 31, 2009 / Notices 38205 

TABLE 2—DETAILED ESTIMATE OF RESPONDENT BURDEN—Continued 

[Note: Total burden is annualized over a 3-year period.] 

Instrument Respondent Number of 

respondents 

Total average 

number of 

responses per 

respondent 

Hours per 

response 

Total burden 

hours 

3-year average annual 

burden hours 

Delinquency Survey—Revised (DS– 

R).

Youth ................... 7 5,286 3 0 .167 2,648 883 

Behavioral and Emotional Rating 

Scale—Second Edition, Youth 

Rating Scale (BERS–2Y).

Youth ................... 5,286 3 0 .167 2,648 883 

Gain-Quick Substance Related 

Issues (Gain Quick-R).

Youth ................... 5,286 3 0 .083 1,316 439 

Substance Use Survey—Revised 

(SUS–R).

Youth ................... 5,286 3 0 .100 1,586 529 

Revised Children’s Manifest Anxiety 

Scales (RCMAS).

Youth ................... 5,286 3 0 .050 793 264 

Reynolds Adolescent Depression 

Scale—Second Edition (RADS–2).

Youth ................... 5,286 3 0 .050 793 264 

Youth information Questionnaire— 

Baseline (YIQ–I).

Youth ................... 5,286 1 0 .167 883 294 

Youth information Questionnaire— 

Follow-up (YIQ–F).

Youth ................... 5,286 2 0 .167 1,766 589 

Service Experience Study 

Multi-Sector Service Contacts—Revised (MSSC–R).Caregiver ............ 8,810 8 2 0 .250 4,405 1,468 

Evidence-Based Practice Measure 

(EBPEM).

Caregiver ............ 8,810 2 0 .167 2,943 981 

Cultural Competence and Service 

Provision Questionnaire (CCSP).

Caregiver ............ 8,810 2 0 .167 2,943 981 

Youth Services Survey—Family 

(YSS–F).

Caregiver ............ 8,810 2 0 .117 2,062 687 

Youth Services Survey (YSS) .......... Youth ................... 5,286 2 0 .083 877 292 

Services and Costs Study 

Flex Funds Data Dictionary .............. Local staff compiling/entering 

data.

9 2,670 10 3 0 .033 218 73 

Services and Costs Data Dictionary Local staff compiling/entering 

data.

11 10,680 12 100 0 .033 29,073 9,691 

Sustainability Study 

Sustainability Survey—Caregiver ..... 13 Caregiver ......... 52 2 0 .75 78 26 

Sustainability Survey—Provider ....... 13Provider/Administrator.156 2 0 .75 234 78 

CQI Benchmarking Initiative Evaluation 

CQI Initiative Survey ......................... Key community 

staff.

150 1 0 .5 75 25 

CQI Initiative Interview Guide ........... Key community 

staff.

50 1 1 .0 50 17 

Evidence-Based Practices Study 

The Implementation Factors Discussion Guide.SOC leadership 

team member.

90 1 0 .75 68 23 

The Implementation Factors Discussion Guide.Provider ............... 60 1 0 .75 45 15 

The Implementation Factors Discussion Guide.Caregivers ........... 30 1 0 .5 15 5 

Cultural and Linguistic Competence Study 

CCIOSAS—Beneficiaries of Self-Assessment Findings.Provider ............... 40 1 1 .0 40 13 

CCIOSAS—Beneficiaries of Self-Assessment Findings.Administrators/ 

Managers.

20 1 1 .5 30 10 


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38206 Federal Register / Vol. 74, No. 146 / Friday, July 31, 2009 / Notices 

TABLE 2—DETAILED ESTIMATE OF RESPONDENT BURDEN—Continued 

[Note: Total burden is annualized over a 3-year period.] 

Instrument Respondent Number of 

respondents 

Total average 

number of 

responses per 

respondent 

Hours per 

response 

Total burden 

hours 

3-year average annual 

burden hours 

CCIOSAS—Beneficiaries of Self-Assessment Findings.Caregivers ........... 40 1 0 .75 30 10 

CCIOSAS—Beneficiaries of Self-Assessment Findings.Youth ................... 40 1 0 .75 30 10 

CCIOSAS—Participants in Self-Assessments.Provider ............... 40 1 1 .0 40 13 

CCIOSAS—Participants in Self-Assessments.Administrators/ 

Managers.

20 1 1 .5 30 10 

CCIOSAS—Participants in Self-Assessments.Caregivers ........... 16 1 0 .75 12 4 

CCIOSAS—Participants in Self-Assessments.Youth ................... 16 1 0 .75 12 4 

CCIOSAS—Users of Self-Assessment Findings.Provider ............... 40 1 1 .0 40 13 

CCIOSAS—Users of Self-Assessment Findings.Administrators/ 

Managers.

20 1 1 .5 30 10 

CCIOSAS—Users of Self-Assessment Findings.Caregivers ........... 16 1 0 .75 12 4 

CCIOSAS—Users of Self-Assessment Findings.Youth ................... 16 1 0 .75 12 4 

CCIOSAS—Telephone Interview ..... Providers ............. 2 1 1 .0 2 0.67 

CCIOSAS—Telephone Interview ..... Administrators/ 

Managers.

3 1 1 .0 3 1 

CCEBPS—Managers of EBP Process.Providers ............. 16 1 1 .0 16 5 

CCEBPS—Managers of EBP Process.Administrators/ 

Managers.

20 1 1 .5 30 10 

CCEBPS—Providers of EBP ............ Providers ............. 40 1 1 .0 40 13 

CCEBPS—Families and Youth ........ Caregivers ........... 40 1 0 .75 30 10 

CCEBPS—Families and Youth ........ Youth ................... 40 1 0 .75 30 10 

CCEBPS—Telephone Interview ....... Providers ............. 2 1 1 .0 2 0.67 

CCEBPS—Telephone Interview ....... Administrators/ 

Managers.

3 1 1 .0 3 1 

TABLE 2—ESTIMATE OF RESPONDENT BURDEN (CONTINUED) 

Number of 

distinct respondents 

Number of 

responses per 

year per 

respondent 

Average annual burden 

per response 

(hours) 

Total annual 

burden 

(hours) 

Summary of Annualized Burden Estimates for 3 Years 

Caregivers ........................................................................................................ 8,810 2.46 2.36 51,147 

Youth ................................................................................................................ 5,286 2.56 0.99 13,397 

Community staff ............................................................................................... 870 72.22 0.86 54,035 

Total Summary ......................................................................................... 14,996 6.54 ........................ 118,579 

Total Annual Average Summary ....................................................... 4,989 2.18 ........................ 39,526 

1An average of 21 constituents in up to 30 grant communities will complete the System of Care Assessment interview. These constituents will 

include site administrative staff, providers, agency representatives, family representatives, and youth. 2 Number of respondents across 30 grantees. Average based on a 5 percent attrition rate at each data collection point. 

3Average number of responses per respondent is a weighted average of the possible numbers of responses per respondent for communities 

beginning data collection in FY2007 and FY2008. The maximum numbers of responses per respondent are for 24 communities beginning data 

collection in FY2007, 1 follow-up data collection point remaining for children/youth recruited in year 2 (of grant community funding), 3 for children/ 

youth recruited in year 3, 4 for children/youth recruited in year 4, and 4 for children/youth recruited in year 5. The maximum numbers of responses per respondent are, for 6 communities beginning data collection in FY2008, 3 follow-up data collection points remaining for children/ 

youth recruited in year 2 (of grant community funding), 5 for children/youth recruited in year 3, 6 for children/youth recruited in year 4, and 4 for 

children/youth recruited in year 5. 4Approximate number of caregivers with children over age 5, based on Phase V data submitted as of 12/08. 

5Approximate number of caregivers with children 3 and older, based on Phase V data submitted as of 12/08. 

6Approximate number of caregivers with children 5 or under, based on Phase V data submitted as of 12/08. 

7Based on Phase III and IV finding that approximately 60 percent of the children/youth in the evaluation were 11 years old or older. 8 Respondents only complete Service Experience Study measures at follow-up points. See Footnote #3 for the explanation about the average 

number of responses per respondent. 


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9Staff will enter data on flexible funds expenditures into a Web-based application or will recode existing data on flexible funds expenditures to 

match the Flex Funds Data Dictionary format. Each community will use flexible funds expenditures on average for approximately one-quarter of 

the estimated 356 children/youth enrolled, suggesting a total of 89 children/youth will receive services from flexible funds per community. Thus, 

there will be data entered for 89 × 30 = 2,670 children/youth using the Flex Funds Data Dictionary. 10Assumes that three expenditures, on average, will be spent on each child/youth receiving flexible fund benefits. 11Staff will collect paper-based forms from agencies and enter them into a Web-based application or will extract data from agencies’ existing 

data systems. Staff will recode data to match the Services and Costs Data Dictionary format. Service and costs records will be compiled for all 

356 × 30 = 10,680 children/youth enrolled. 12Assumes that each child/youth will have 100 service episodes, on average, during his/her time in a system of care. 13This survey will be administered in 5 communities funded in 2006, 25 communities funded in 2005, 2 communities funded in 2000, and 20 

communities funded in 1999. For each community, one respondent will be a caregiver and three respondents will be administrators/providers. 

Written comments and 

recommendations concerning the 

proposed information collection should 

be sent by August 31, 2009 to: SAMHSA 

Desk Officer, Human Resources and 

Housing Branch, Office of Management 

and Budget, New Executive Office 

Building, Room 10235, Washington, DC 

20503; due to potential delays in OMB’s 

receipt and processing of mail sent 

through the U.S. Postal Service, 

respondents are encouraged to submit 

comments by fax to: 202–395–6974. 

Dated: July 27, 2009. 

Elaine Parry, 

Director, Office of Program Services. 

[FR Doc. E9–18315 Filed 7–30–09; 8:45 am] 

BILLING CODE 4162–20–P 

DEPARTMENT OF HEALTH AND 

HUMAN SERVICES 

Centers for Medicare & Medicaid 

Services 

[Document Identifier: CMS–43, CMS–1763, 

CMS–R–194 and CMS–R–296] 

Agency Information Collection 

Activities: Submission for OMB 

Review; Comment Request 

AGENCY: 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: Extension of a currently 

approved collection; Title of 

Information Collection: Application for 

Hospital Insurance Benefits for 

Individuals with End Stage Renal 

Disease: Use: Effective July 1, 1973, 

individuals with End Stage Renal 

Disease (ESRD) became entitled to 

Medicare. Because this entitlement has 

a different set of requirements, the 

existing applications for Medicare were 

not sufficient to capture the information 

needed to determine Medicare 

entitlement under the ESRD provisions 

of the law. The Application for Hospital 

Insurance Benefits for Individuals with 

End Stage Renal Disease, was designed 

to capture all the information needed to 

make a Medicare entitlement 

determination; Form Numbers: CMS–43 

(OMB#: 0938–0800; Frequency: 

Reporting—Once; Affected Public: 

Individuals or households; Number of 

Respondents: 60,000; Total Annual 

Responses: 60,000; Total Annual Hours: 

25989. (For policy questions regarding 

this collection contact Naomi Rappaport 

at 410–786–2175. For all other issues 

call 410–786–1326.) 

2. Type of Information Collection 

Request: Extension of a currently 

approved collection; Title of 

Information Collection: Request for 

Termination of Premium Hospital and/ 

or Supplementary Medical Insurance: 

Use: The Social Security Act (the Act) 

allows a Medicare enrollee to 

voluntarily terminate Supplementary 

Medical Insurance (Part B) and/or the 

premium Hospital Insurance (premiumPart A) coverage by filing a written 

request with CMS or the Social Security 

Administration (SSA). The Act also 

stipulates when coverage will end based 

upon the date the request was filed. 

Because Medicare is recognized as a 

valuable protection against the high cost 

of medical and hospital bills, when an 

individual wishes to voluntarily 

terminate Part B and/or premium Part 

A, CMS and SSA requests the reason 

that an individual wishes to terminate 

coverage to ensure that the individual 

understands the ramifications of the 

decision. The Request for Termination 

of Premium Hospital and/or 

Supplementary Medical Insurance, 

provides a standardized form to satisfy 

the requirements of law as well as 

allowing both agencies to protect the 

individual from an inappropriate 

decision; Form Numbers: CMS–1763 

(OMB#: 0938–0025; Frequency: 

Reporting—Once; Affected Public: 

Individuals or households; Number of 

Respondents: 14,000; Total Annual 

Responses: 14,000; Total Annual Hours: 

5,831. (For policy questions regarding 

this collection contact Naomi Rappaport 

at 410–786–2175. For all other issues 

call 410–786–1326.) 

3. Type of Information Collection 

Request: Extension of a currently 

approved collection; Title of 

Information Collection: Medicare 

Disproportionate Share Adjustment 

Procedures and Criteria and Supporting 

Regulations in 42 CFR 412.106: Use: 

Section 1886(d)(5)(F) of the Social 

Security Act established the Medicare 

disproportionate share adjustment 

(DSH) for hospitals, which provides 

additional payment to hospitals that 

serve a disproportionate share of the 

indigent patient population. This 

payment is an add-on to the set amount 

per case CMS pays to hospitals under 

the Medicare Inpatient Prospective 

Payment System (IPPS). 

Under current regulations at 42 CFR 

412.106, in order to meet the qualifying 

criteria for this additional DSH 

payment, a hospital must prove that a 

disproportionate percentage of its 

patients are low income using 

Supplemental Security Income (SSI) 

and Medicaid as proxies for this 

determination. This percentage includes 

two computations: (1) The ‘‘Medicare 

fraction’’ or the ‘‘SSI ratio’’ which is the 

percent of patient days for beneficiaries 

who are eligible for Medicare Part A and 

SSI and (2) the ‘‘Medicaid fraction’’ 

which is the percent of patient days for 

patients who are eligible for Medicaid 

but not Medicare. Once a hospital 

qualifies for this DSH payment, CMS 

also determines a hospital’s payment 

adjustment; Form Numbers: CMS–R– 

194 (OMB#: 0938–0691; Frequency: 

Reporting—Occasionally; Affected 

Public: Business or other for-profit and 

Not-for-profit institutions; Number of 

Respondents: 800; Total Annual 

Responses: 800; Total Annual Hours: 


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