Burden for years 1 and 2

Patient Safety Survey Under the 9th SOW: Nursing Home In Need (NHIN)

Documents and Forms

Document Name Document Type
Form CMS-10315 Burden for years 1 and 2 Form and Instruction
CMS-10315 Nursing Home In Need (NHIN) Survey CMS-10315.NHIN Survey.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Burden for years 1 and 2	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10315	Nursing Home In Need (NHIN) Survey	CMS-10315.NHIN Survey.docx		Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 53	Number of Respondents for Small Entity: 0

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

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	106	106
Annual IC Time Burden (Hours)	35	35
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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