Information Collection

Collaborating Center for Questionnaire Design and Evaluation Research (CCQDER)

IC 231481 under ICR 201506-0920-003 · OMB 0920-0222.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0222 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-0222 Collaborating Center for Questionnaire Design and Evaluation Research (CCQDER)	Form and Instruction
0920-0222 National Study of Long-Term Care Provider 2016 Adult Day Attach 1a - ADSC Questionnaire-v2 051418.pdf	Form and Instruction
0920-0222 National Study of Long-Term Care Providers 2016 Resident Attach 1b - RCC Questionnaire-v2 051418.pdf	Form and Instruction
0920-0222 Adult Day Care Services Center (ADSC) Telephone Screenin Attach 3a - ADSC Telephone Screener.docx	Form and Instruction
0920-0222 Residential Care Community (RCC) Telephone Screening Scr Attach 3b - RCC Telephone Screener.docx	Form and Instruction
LTCSB10-day letter 051418.docx LTCSB 10-day Letter	IC Document
Attach 2 - Advance Letter.docx Att 2_Advance Letter	IC Document
Attach 4 - Informed Consent.doc Att 4_Informed Consent	IC Document
Attach 5 - Resp Data Collect Sheet.doc Att 5_Resp Data Collect Sheet	IC Document
Attach 6 - Thank you letter.doc Att 6_Thank you Letter	IC Document
Attach 7 - Special Consent.docx Att 7_Special Consent	IC Document

IC Title:

Collaborating Center for Questionnaire Design and Evaluation Research (CCQDER)

Agency IC Tracking Number:

0920-0222 (18AGM)

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?	Electronic Capability
Form and Instruction	0920-0222	National Study of Long-Term Care Provider 2016 Adult Day Services Center Questionnaire	Attach 1a - ADSC Questionnaire-v2 051418.pdf	No	Fillable Fileable
Form and Instruction	0920-0222	Adult Day Care Services Center (ADSC) Telephone Screening Script	Attach 3a - ADSC Telephone Screener.docx	No	Fillable Fileable
Form and Instruction	0920-0222	Residential Care Community (RCC) Telephone Screening Script	Attach 3b - RCC Telephone Screener.docx	No	Fillable Fileable
Form and Instruction	0920-0222	National Study of Long-Term Care Providers 2016 Residential Care Community Questionnaire	Attach 1b - RCC Questionnaire-v2 051418.pdf	No	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: Health and Demongraphic Surveys Conducted in Probability Samples of the U.S. Population

FR Citation: 49 FR 37693

Number of Respondents: 112

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

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	112	112
Annual IC Time Burden (Hours)	46	46
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
LTCSB 10-day Letter	LTCSB10-day letter 051418.docx	05/17/2018
Att 2_Advance Letter	Attach 2 - Advance Letter.docx	05/17/2018
Att 4_Informed Consent	Attach 4 - Informed Consent.doc	05/17/2018
Att 5_Resp Data Collect Sheet	Attach 5 - Resp Data Collect Sheet.doc	05/17/2018
Att 6_Thank you Letter	Attach 6 - Thank you letter.doc	05/17/2018
Att 7_Special Consent	Attach 7 - Special Consent.docx	05/17/2018

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