Form Cms-1882 - Portable Xray Survey Report Page 10

name of facility

met not

n/a

standards

code

eXplanatory statement

met

date of last

inspecting agency

inspector’s statement

H57

inspection

maintained

yes

Inspector’s Qualifications

according to the paperwork reduction act of 1995, no persons are required to respond to a collection of information unless it displays a valid omb control number. the valid omb control number for this

information collection is 0938-0027. The time required to complete this information collection is estimated to average 2 hours per response, including the time to review instructions, search existing data

resources, gather the data needed, and complete and review the information collection. if you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form,

please write to: cms, attn: pra reports clearance, 7500 security boulevard, baltimore, maryland 21244-1850.

form cms-1882 (02/09)