Information Collection

Alzheimer's Disease Supportive Services Program (ADSSP) Data Collection

IC 178976 under ICR 201006-0985-001 · OMB 0985-0022.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0985-0022 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
ADSSP Data Collection Reporting Form (2).xls	Other-fillable spreadsheet
ADSSP Template for Data Collection (2).doc	Other-fillable template
2 of 3 ADSSP Definitions for Data Collection.doc ADSSP Definitions	IC Document

IC Title:

Alzheimer's Disease Supportive Services Program (ADSSP) Data Collection

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

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-fillable template			ADSSP Template for Data Collection (2).doc		Yes	Yes	Fillable Fileable
Other-fillable spreadsheet			ADSSP Data Collection Reporting Form (2).xls		Yes	Yes	Fillable Fileable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 47

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	94	56	38
Annual IC Time Burden (Hours)	1,410	460	950
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
ADSSP Definitions	2 of 3 ADSSP Definitions for Data Collection.doc	05/20/2010

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