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

Data Collection for Developing Outpatient Therapy Payment Alternatives (DOTPA)

Documents and Forms

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

Information Collection (IC) Details

IC Title:	Data Collection for Developing Outpatient Therapy Payment Alternatives (DOTPA): Data Collection in Facility-Based Settings	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection 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 %

	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

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.