Contact Information Verification

Frame Development for the National Survey of Long-Term Providers

Documents and Forms

Document Name Document Type
Contact Information Verification Form
Contact Information Verification Attachment C 1-Advance Package Contact Info Verification.doc Form
Attachment C 2-Advance Package NCHS Cover Letter.doc Advance Package Cover Letter IC Document
Attachment C 3-Advance Package NCHS Confidentiality Brochure.doc Advance Package Confidentiality Brochure IC Document

Information Collection (IC) Details

IC Title:	Contact Information Verification	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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
Form	none	Contact Information Verification	Attachment C 1-Advance Package Contact Info Verification.doc		Yes	Yes	Fillable Fileable

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: 34	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	34	34
Annual IC Time Burden (Hours)	3	3
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Advance Package Cover Letter	Attachment C 2-Advance Package NCHS Cover Letter.doc	06/05/2013
Advance Package Confidentiality Brochure	Attachment C 3-Advance Package NCHS Confidentiality Brochure.doc	06/05/2013

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