National Survey of Residential Care Facilities (NSRCF) 2008-2010

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 8 National Survey Resident Questionnaire	Form and Instruction	New	Available
Form 7 National Survey Facility Questionnaire	Form and Instruction	New	Available
Form 6 Line 6 National Survey Advance Data Collection Form	Form and Instruction	New	Available
Form 5 National Survey Facility Screener	Form and Instruction	New	Available
Form 4 Pretest Resident Questionnaire	Form and Instruction	New	Available
Form 3 Pretest Facility Questionnaire	Form and Instruction	New	Available
Form 1 Pretest Facility Screener	Form	New	Available
Form 1 Pretest Advance Data Collection Form	Form	New	Available
Attachment L-Ethic Review Board.doc	Supplementary Document	Uploaded 2008-03-26	Repair queued
SS Part B.doc	Supporting Statement B	Uploaded 2008-01-15	Available
NSRCF Attachment E-Advance Letter rev 0608.doc	Supplementary Document	Uploaded 2008-06-18	Available
Attachment D-Instrument Reviewers.doc	Supplementary Document	Uploaded 2008-01-17	Available
Attachment B-2--60-day notice comment.doc	Supplementary Document	Uploaded 2008-01-17	Available
Attachment B-1 RE public comment on federal register of today #188 pg 55217 dhs - cdc 60 day 07 0920-07BR.txt	Supplementary Document	Uploaded 2008-01-17	Available
Attachment C-Expert Panelumbers.doc	Supplementary Document	Uploaded 2008-01-17	Available
Attachment A-NCHS Legislation.doc	Supplementary Document	Uploaded 2008-01-17	Available
Attachment K-Resident Showcards2.doc	Supplementary Document	Uploaded 2008-01-17	Available
Attachment J-Facility Showcards.doc	Supplementary Document	Uploaded 2008-01-17	Available
Attachment G-Pretest Advance Data Collection Form.doc	Supplementary Document	Uploaded 2008-01-16	Available
NSRCF Supporting Statement FINAL Part A rev 3 0608.doc	Supporting Statement A	Uploaded 2008-06-18	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
183894	Line 8 National Survey Resident Questionnaire	Form and Instruction	New	National Survey Resident Questionnaire
183893	Line 7 National Survey Facility Questionnaire	Form and Instruction	New	National Survey Facility Questionnaire
183892	Line 6 National Survey Advance Data Collection Form	Form and Instruction	New	Line 6 National Survey Advance Data Collection Form
183891	Line 5 National Survey Facility Screener	Form and Instruction	New	National Survey Facility Screener
183890	Line 4 Pretest Resident Questionnaire	Form and Instruction	New	Pretest Resident Questionnaire
183889	Line 3 Pretest Facility Questionnaire	Form and Instruction	New	Pretest Facility Questionnaire
183888	Line 1 Pretest Facility Screener	Form	New	Pretest Facility Screener
183887	Line 2 Pretest Advance Data Collection Form	Form	New	Pretest Advance Data Collection Form

ICR Details

OMB Control No: 0920-0780	ICR Reference No: 200802-0920-012
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CDC	Agency Tracking No:
Title: National Survey of Residential Care Facilities (NSRCF) 2008-2010
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 06/23/2008
Retrieve Notice of Action (NOA)	Date Received in OIRA: 02/25/2008
Terms of Clearance: Clearance is only provided for conducting the pilot test described in this ICR. Whereas OMB supports the concept of the National Survey of Residential Care Facilities, we understand that full funding is not currently available, thus it is not possible for NCHS to specify (or OMB to evaluate) the sampling design to be applied in a national study. The current 18 month approval period is designed to allow sufficient time for incorporation of the results of the testing into the final protocol. NCHS must submit a full change/revision package to OMB before fielding the national study.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2009	36 Months From Approved
Responses	6,200	0	0
Time Burden (Hours)	2,778	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The National Survey of Residential Care Facilities will produce national estimates on the numbers of residential care facilities in the US and the number of residents receiving care. It will provide estimates on the characteristics of both the facilities and the residents.

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Authorizing Statute(s): US Code: 42 USC 306 Name of Law: Public Health Service Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	72 FR 55217	09/28/2007
30-day Notice:	Federal Register Citation:	Citation Date:
	73 FR 4577	01/25/2008
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 8

table that charts list of burden

IC Title	Form No.	Form Name
Line 1 Pretest Facility Screener	1	Pretest Facility Screener
Line 2 Pretest Advance Data Collection Form	1	Pretest Advance Data Collection Form
Line 3 Pretest Facility Questionnaire	3	Pretest Facility Questionnaire
Line 4 Pretest Resident Questionnaire	4	Pretest Resident Questionnaire
Line 5 National Survey Facility Screener	5	National Survey Facility Screener
Line 6 National Survey Advance Data Collection Form	6	Line 6 National Survey Advance Data Collection Form
Line 7 National Survey Facility Questionnaire	7	National Survey Facility Questionnaire
Line 8 National Survey Resident Questionnaire	8	National Survey Resident Questionnaire

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ICR Summary of Burden

table that charts list 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	6,200	0	0	6,200	0	0
Annual Time Burden (Hours)	2,778	0	0	2,778	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: Miscellaneous Actions

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

Burden Reduction Due to:

Short Statement: This is a new data collection.

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Annual Cost to Federal Government: $2,053,393

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: 02/25/2008

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