State Annual Long-Term Care Ombudsman Report

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
REVISED 060508 OMB 2009-11 Supporting Statement.doc	Supporting Statement A	Uploaded 2009-06-05	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
10249	State Annual Long-Term Care Ombudsman Report		Modified

ICR Details

OMB Control No: 0985-0005	ICR Reference No: 200906-0985-001
Status: Historical Active	Previous ICR Reference No: 200604-0985-001
Agency/Subagency: HHS/ACL	Agency Tracking No:
Title: State Annual Long-Term Care Ombudsman Report
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 07/24/2009
	Date Received in OIRA: 06/24/2009
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2012	36 Months From Approved	07/31/2009
Responses	52	0	52
Time Burden (Hours)	10,310	0	10,258
Cost Burden (Dollars)	0	0	0

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Abstract: The State Annual Long Term Care Ombudsman Report is needed to: comply with state and Administration on Aging reporting requirements in the Older Americans Act; carry out recommendations made by the General Accounting Office, the Department of Health and Human Services' Office of the Inspector General, and the Institute of Medicine; advocate at the state and federal levels for changes needed to improve the quality of life and care in long-term care facilities; and effectively manage the Long-Term Care Ombudsman Program at the local, state and federal levels. The report form and instructions have been in continuous use, with minor modifications, since they were first approved by OMB for the FY 1995 reporting period. This request is for approval to extend use of the current form and instructions, with no modifications, for three years, covering the FY 2009-2011 reporting periods.

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Authorizing Statute(s): PL: Pub.L. 109 - 365 712 (c),(h)(1)-(3) Name of Law: Older Americans 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:
	74 FR 7694	02/19/2009
30-day Notice:	Federal Register Citation:	Citation Date:
	74 FR 20706	05/05/2009
Did the Agency receive public comments on this ICR? Yes

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

table that charts list of burden

IC Title	Form No.	Form Name
State Annual Long-Term Care Ombudsman Report

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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	52	52	0	0	0	0
Annual Time Burden (Hours)	10,310	10,258	0	0	52	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

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

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: $199,369

Does this IC contain surveys, censuses, or employ statistical methods? No

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)? No

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: 06/24/2009

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