Testing Long-term Care Questions

NCHS Questionnaire Design Research Laboratory

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0222 can be found here:

Documents and Forms

Document Name Document Type
Testing Long-term Care Questions Form
NSLTP - Adult Day Services Center QDRL OMB-10-day letter LTC Att 1b - LTC RCC Questionaire 061113.docx Form
NSLTP - Residential Care Community QDRL OMB-10-day letter LTC Attt 1a - LTC RCC Questionaire 061113.docx Form
Screeners QDRL OMB-10-day package LTC Att 3ab - LTC Telephone Screener 06102013.docx Form and Instruction
QDRL OMB-10-day letter LTC Att 2 - LTC Advance Letter 06102013.docx Advance Letter IC Document
QDRL OMB-10-day letter LTC 10-day letter-06102013.docx Letter to Dr. Schwab IC Document

Information Collection (IC) Details

IC Title:	Testing Long-term Care Questions	Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	none	NSLTP - Adult Day Services Center	QDRL OMB-10-day letter LTC Att 1b - LTC RCC Questionaire 061113.docx	Yes	Yes	Fillable Fileable
Form	none	NSLTP - Residential Care Community	QDRL OMB-10-day letter LTC Attt 1a - LTC RCC Questionaire 061113.docx	Yes	Yes	Fillable Fileable
Form and Instruction	none	Screeners	QDRL OMB-10-day package LTC Att 3ab - LTC Telephone Screener 06102013.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title: Health and Demographic Surveys Conducted in Probability Samples of the US Population	FR Citation: 49 FR 37693

Number of Respondents: 26	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: 100 %

	Approved	Program Change Due to New Statute	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA	Previously Approved
Annual Number of Responses for this IC	26	0	0	0	0	0
Annual IC Time Burden (Hours)	26	0	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Advance Letter	QDRL OMB-10-day letter LTC Att 2 - LTC Advance Letter 06102013.docx	06/13/2013
Letter to Dr. Schwab	QDRL OMB-10-day letter LTC 10-day letter-06102013.docx	06/13/2013

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