Information Collection

57.137 Long Term care Facility Component--Annual Facility Survey

IC 197541 under ICR 201211-0920-005 · 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⚠️ Notice: This information collection may be referencing outdated material.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
57.137_LTCFSurv_BLANK.docx	Other-WORD
LTC TOI Annual Facility Survey.docx LTC TOI Annual Facility Survey	IC Document

IC Title:

57.137 Long Term care Facility Component--Annual Facility Survey

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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			57.137_LTCFSurv_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 Agency Discretion	Previously Approved
Annual Number of Responses for this IC	250	0	250
Annual IC Time Burden (Hours)	188	84	104
Annual IC Cost Burden (Dollars)	7,247	7,247	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
LTC TOI Annual Facility Survey	LTC TOI Annual Facility Survey.docx	12/05/2011

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