State Annual Long-Term Care Ombudsman Report

Forms and Documents

Document Name	Status
Form 0985-0005 State Annual Long-Term Care Ombudsman Report Form	Modified
OMB 2012-2014 Supporting Statement final 3-15-12.doc Supporting Statement A	2012-05-01

IC Document Collections

IC ID	Document Title	Status
10249	State Annual Long-Term Care Ombudsman Report Form	Modified

ICR Details

OMB Control No: 0985-0005	ICR Reference No: 201205-0985-001
Status: Historical Active	Previous ICR Reference No: 200906-0985-001
Agency/Subagency: HHS/ACL	Agency Tracking No:
Title: State Annual Long-Term Care Ombudsman Report
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 07/03/2012
	Date Received in OIRA: 05/04/2012
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2015	36 Months From Approved	07/31/2012
Responses	52	0	52
Time Burden (Hours)	8,569	0	10,310
Cost Burden (Dollars)	0	0	0

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Abstract: The State Annual Long Term Care Ombudsman Report is needed to: comply with state and Administration on Aging reporting requirements in the Older Americans Act; carry out recommendations made by the General Accounting Office, the Department of Health and Human Services' Office of the Inspector General, and the Institute of Medicine; advocate at the state and federal levels for changes needed to improve the quality of life and care in long-term care facilities; and effectively manage the Long-Term Care Ombudsman Program at the local, state and federal levels. The report form and instructions have been in continuous use, with minor modifications, since they were first approved by OMB for the FY 1995 reporting period.

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Authorizing Statute(s): PL: Pub.L. 109 - 365 712 (c),(h)(1)-(3) Name of Law: Older Americans Act
   US Code: 42 USC chapter 35 Name of Law: Programs for Older Americans
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 1693	01/11/2012
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 17482	03/26/2012
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
State Annual Long-Term Care Ombudsman Report	0985-0005	National Ombudsman Reporting System

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	52	52	0	0	0	0
Annual Time Burden (Hours)	8,569	10,310	0	0	-1,741	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: Adjustments in respondents' burden hours from the previously approved request are due to changes in the number of closed cases reported by all states. The base year of the previous request was FY 2007 and 184,177 cases were reported. The base year of this request was FY2010 with 139,269 cases reported.

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Annual Cost to Federal Government: $197,087

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 05/04/2012

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