Information Collection

Interviews for the National Study of Long-term Care Providers Gaps Project

IC 222776 under ICR 201407-0920-008 · OMB 0920-1030.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1030 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Interviews for the National Study of Long-term Care Providers Gaps Project	Form and Instruction
Attachment D-1-Interview for Researchers and Association Representatives_071916.docx	Other-Interview script
Attachment D-2-Interview for State Agency Staff_071916.docx	Other-Interview script
Scheduling script Attachment C-1 Scheduling Script A_071916.doc	Form and Instruction
Scheduling script B Attachment C-2 Scheduling Script B_071916.doc	Form and Instruction
Gaps Project SSA_072716.doc Supporting Statement A	IC Document
Gaps Project SSB_072716.doc Supporting Statement B	IC Document
Attachment A-Non Human Subjects Research Determination.pdf Research determination	IC Document
Attachment B-Introductory email_071916.doc Introductory email	IC Document

IC Title:

Interviews for the National Study of Long-term Care Providers Gaps Project

Agency IC Tracking Number:

16AWG

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	none	Scheduling script	Attachment C-1 Scheduling Script A_071916.doc	Yes	No	Paper Only
Form and Instruction	none	Scheduling script B	Attachment C-2 Scheduling Script B_071916.doc	Yes	No	Paper Only
Other-Interview script			Attachment D-1-Interview for Researchers and Association Representatives_071916.docx	Yes	No	Paper Only
Other-Interview script			Attachment D-2-Interview for State Agency Staff_071916.docx	Yes	No	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: Health Resources Utilization Statistics

FR Citation: 49 FR 37697

Number of Respondents: 36

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	36	36
Annual IC Time Burden (Hours)	20	20
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Supporting Statement A	Gaps Project SSA_072716.doc	08/01/2016
Supporting Statement B	Gaps Project SSB_072716.doc	08/01/2016
Research determination	Attachment A-Non Human Subjects Research Determination.pdf	08/01/2016
Introductory email	Attachment B-Introductory email_071916.doc	08/01/2016

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