Information Collection

Adult Day Services Center Questionnaire

IC 202804 under ICR 201402-0920-003 · OMB 0920-0943.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0943 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Adult Day Services Center Questionnaire	Form
ADSC Questions Attachment B-1 2014 ADSC questions 013014.docx	Form

IC Title:

Adult Day Services Center Questionnaire

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
Form	none	ADSC Questions	Attachment B-1 2014 ADSC questions 013014.docx		Yes	No	Printable Only

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title: Health Resources Utilization Statistics

FR Citation: 49 FR 37697

Number of Respondents: 5,000

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 15 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	5,000	5,000
Annual IC Time Burden (Hours)	2,500	2,500
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.