2004 National Long-Term Care Survey (NLTCS); Informal Caregivers Survey (ICS)

Forms and Documents

Document Name	Status

No forms / supporting documents in this ICR. Check IC Document Collections.

IC Document Collections

IC ID	Document Title	Status
3506	2004 National Long-Term Care Survey (NLTCS); Informal Caregivers Survey (ICS) Form	Migrated

ICR Details

OMB Control No: 0607-0778	ICR Reference No: 200407-0607-002
Status: Historical Active	Previous ICR Reference No: 200003-0607-013
Agency/Subagency: DOC/CENSUS	Agency Tracking No:
Title: 2004 National Long-Term Care Survey (NLTCS); Informal Caregivers Survey (ICS)
Type of Information Collection: Reinstatement with change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 09/10/2004
	Date Received in OIRA: 07/14/2004
Terms of Clearance: Census shall add the following statement to materials given to respondents: " In addition, Duke University may use the information to contact you for supplemental studies. Like this survey, your decision to participate in a supplemental study is strictly voluntary." Prior to the fielding of this survey, Census shall provide to OMB via email a revision of the CMS letter found at Attachment F. The revision should either delete the instruction to contact 1800-MEDICARE if the R has questions or provide a contact number that will enable the R to speak with someone knowledgeable about the survey. Census will also delete 'other' from the flashcard showing race categories.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2005	12/31/2005
Responses	32,300	0	0
Time Burden (Hours)	9,891	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: We are conducting the 2004 NLTCS and the ICS at the request of the Duke University. The NLTCS and the ICS obtains information on the health conditions and healthcare needs of people 65 years old and older, and the people and nursing care facilities who take care of them. The information helps determine how to meet the future healthcare needs of people 65 years old and older.

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Authorizing Statute(s): None

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:

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Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
2004 National Long-Term Care Survey (NLTCS); Informal Caregivers Survey (ICS)	LTC-9(L2), LTC-9(L3), LTC-9(L4), LTC-4

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	32,300	0	0	32,300	0	0
Annual Time Burden (Hours)	9,891	0	0	9,891	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 07/14/2004

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