Information Collection

Testing Long Term Care Questions

IC 199221 under ICR 201002-0920-006 · OMB 0920-0222.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0222 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
QDRL LTC Attach 1-v2.docx	Other-Interview
QDRL LTC 10-day letter-final 2mary.doc Letter to Margo Schwab	IC Document

IC Title:

Testing Long Term Care Questions

Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Interview			QDRL LTC Attach 1-v2.docx		Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: 09-20-0164 Health and Demographic Surveys Conducted in Probability Samples of the U.S. Population

FR Citation: 49 FR 37693

Number of Respondents: 15

Number of Respondents for Small Entity: 5

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to New Statute	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA	Previously Approved
Annual Number of Responses for this IC	15	0	0	0	0	0
Annual IC Time Burden (Hours)	15	0	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Letter to Margo Schwab	QDRL LTC 10-day letter-final 2mary.doc	09/13/2011

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.