Contact Information Verification

Frame Development for the National Survey of Long-Term Providers

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0912 can be found here:

Documents and Forms

Document Name Document Type
Attachment D 1-Advance Package Contact Info Verification 11-23.doc Instruction
Attachment D 2-Advance Package NCHS Cover Letter.doc Attachment D2 Advance Package Cover Letter IC Document
Attachment D 3-Advance Package Prof Assoc Letter.doc Attachment D 3 Advance Package Professional Assoc Letter IC Document
Attachment D 4-Advance Package NCHS Confidentiality Brochure.doc Attachment D 4 Confidentiality Letter IC Document

Information Collection (IC) Details

IC Title:	Contact Information Verification	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
Instruction			Attachment D 1-Advance Package Contact Info Verification 11-23.doc		Yes	Yes	Printable Only

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title: Health resrouces Utilization Statistics	FR Citation: 49 FR 37697

Number of Respondents: 51	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	51	51
Annual IC Time Burden (Hours)	4	4
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Attachment D2 Advance Package Cover Letter	Attachment D 2-Advance Package NCHS Cover Letter.doc	12/09/2011
Attachment D 3 Advance Package Professional Assoc Letter	Attachment D 3-Advance Package Prof Assoc Letter.doc	12/09/2011
Attachment D 4 Confidentiality Letter	Attachment D 4-Advance Package NCHS Confidentiality Brochure.doc	12/09/2011

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