Information Collection

Data Collection for Developing Outpatient Therapy Payment Alternatives (DOTPA): Data Collection in Facility-Based Settings

IC 192931 under ICR 201012-0938-004 · OMB 0938-1096.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Appendix A CARE-C_Admission_4-14-2010.pdf	Other-Admission Intake Questionnaire
Appendix A CARE-C_Discharge_4-14-2010.pdf	Other-Discharge Questionnaire
Appendix A CARE-F_Admission_4-14-2010.pdf	Other-Care F Admission Questionnaire
Appendix A CARE-F_Discharge_4-14-2010.pdf	Other-Care F Discharge Questionnaire
Upd 11.10.10 CARE-F_Admission_Nursing Facilities_Highlights_11.10.10_5PM.doc	Other-Care F Admission Questionnaire
Upd 11.10.10_CARE-C_Admission_Highlights_11.10.10_5PM.doc	Other-Care C Admission Questionnaire

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Admission Intake Questionnaire	Appendix A CARE-C_Admission_4-14-2010.pdf	No	No	Paper Only
Other-Discharge Questionnaire	Appendix A CARE-C_Discharge_4-14-2010.pdf	No	No	Paper Only
Other-Care F Admission Questionnaire	Appendix A CARE-F_Admission_4-14-2010.pdf	No	No	Paper Only
Other-Care F Discharge Questionnaire	Appendix A CARE-F_Discharge_4-14-2010.pdf	No	No	Paper Only
Other-Care F Admission Questionnaire: updated	Upd 11.10.10 CARE-F_Admission_Nursing Facilities_Highlights_11.10.10_5PM.doc	No	No	Paper Only
Other-Care C Admission Questionnaire: updated	Upd 11.10.10_CARE-C_Admission_Highlights_11.10.10_5PM.doc	No	No	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 52

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 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	6,088	0	6,088
Annual IC Time Burden (Hours)	4,502	971	3,531
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
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.