Information Collection

Standard of Care Survey

IC 220450 under ICR 201603-0920-004 · OMB 0920-1133.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1133 can be found here:

Documents and Forms

Document Name Document Type
Standard of Care Survey Form
MA Standard of Care Survey Att 8_Mass Standard of Care Survey.docx Form
CT Standard of Care Survey Att 9_Conn Standard of Care Survey.docx Form
Phila Standard of Care Survey Att 10_Phil Standard of Care Survey.docx Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Standard of Care Survey	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	none	MA Standard of Care Survey	Att 8_Mass Standard of Care Survey.docx	Yes	Yes	Fillable Fileable
Form	none	CT Standard of Care Survey	Att 9_Conn Standard of Care Survey.docx	Yes	Yes	Fillable Fileable
Form	none	Phila Standard of Care Survey	Att 10_Phil Standard of Care Survey.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 46	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
Annual Number of Responses for this IC	92	92
Annual IC Time Burden (Hours)	69	69
Annual IC Cost Burden (Dollars)	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.