Information Collection

State Annual Long-Term Care OMBudsman Report

IC 10249 under ICR 201507-0985-002 · OMB 0985-0005.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0985-0005 can be found here:

Documents and Forms

Document Name Document Type
Form 1 State Annual Long-Term Care Ombudsman Report Form
Instructions_Final 2015.pdf Instruction
1 National Ombudsman Reporting System Form_final2015.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	State Annual Long-Term Care Ombudsman Report	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 45 CFR 1321.49

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	1	National Ombudsman Reporting System	Form_final2015.pdf		Yes	Yes	Fillable Fileable
Instruction			Instructions_Final 2015.pdf		Yes	Yes	Fillable Fileable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 52	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	52	0	52
Annual IC Time Burden (Hours)	7,702	-867	8,569
Annual IC Cost Burden (Dollars)	0	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.