Self-administered, Web-based questionnaire

Survey on Long-Term Care Awareness and Planning

Documents and Forms

Document Name Document Type
Form LTC Survey FInal Self-administered, Web-based questionnaire Form
LTC Survey FInal Version 2 LTC Survey_Final aspepra May 2014.docx Form

Information Collection (IC) Details

IC Title:	Self-administered, Web-based questionnaire	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
Form	LTC Survey FInal	Version 2	LTC Survey_Final aspepra May 2014.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 15,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	15,000	15,000
Annual IC Time Burden (Hours)	11,250	11,250
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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