Nursing Home Administrators Survey

Workplace Violence Prevention Programs In New Jersey Healthcare Facilities

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0914 can be found here:

Documents and Forms

Document Name Document Type
Form 0920-0914 Nursing Home Administrators Survey Form and Instruction
0920-0914 Attachment C1 Clean Copy C1 7-21-15.docx Form and Instruction
Highlighted Copy C1 7-21-15.docx Attachment-C1- with changes IC Document

Information Collection (IC) Details

IC Title:	Nursing Home Administrators Survey	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 and Instruction	0920-0914	Attachment C1	Clean Copy C1 7-21-15.docx		Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 7	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	7	0	7
Annual IC Time Burden (Hours)	8	1	7
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Attachment-C1- with changes	Highlighted Copy C1 7-21-15.docx	07/21/2015

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