Pre-test

Pre-test of an Assisted Living Consensus Instrument

Documents and Forms

Document Name Document Type
Form Form #2 Pre-test Form and Instruction
Form #2 Assisted Living Provider Information Tool for Consumer E Attachment D -- AL Provider Info Tool for Consumer Education.pdf Form and Instruction
Attachment H -- Recruitment Letter, Brochure & Followup Postcards.docm Attachment H -- Recruitment Letter, Brochure & Followup Postcards IC Document

Information Collection (IC) Details

IC Title:	Pre-test	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	Form #2	Assisted Living Provider Information Tool for Consumer Education	Attachment D -- AL Provider Info Tool for Consumer Education.pdf		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 191	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	191	191
Annual IC Time Burden (Hours)	80	80
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Attachment H -- Recruitment Letter, Brochure & Followup Postcards	Attachment H -- Recruitment Letter, Brochure & Followup Postcards.docm	07/28/2011

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