Information Collection

57.143 Prevention Process Measures Monthly Monitoring for LTCF

IC 200380 under ICR 201112-0920-004 · OMB 0920-0666.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0666 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
57.143_ProcessMeasureSummaryforLTCF_BLANK.docx	Other-WORD
LTC Prev Process Measures Protocol.docx LTC Prev Process Measures Protocol	IC Document
LTC TOI Prev Process Measures.docx LTC TOI Prev Process Measures	IC Document

IC Title:

57.143 Prevention Process Measures Monthly Monitoring for LTCF

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

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-WORD			57.143_ProcessMeasureSummaryforLTCF_BLANK.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 250

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	3,000	3,000
Annual IC Time Burden (Hours)	250	250
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
LTC Prev Process Measures Protocol	LTC Prev Process Measures Protocol.docx	12/05/2011
LTC TOI Prev Process Measures	LTC TOI Prev Process Measures.docx	12/05/2011

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