Information Collection

2016 Adult Day Services Center Questionnaire-Version B

IC 210276 under ICR 201604-0920-007 · OMB 0920-0943.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0943 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
2016 Adult Day Services Center Questionnaire-Version B	Form
National Study of Long-Term Care Providers--2016 Adult D Att D-4_ 2016 ADSC questions Version B 031816.docx	Form

IC Title:

2016 Adult Day Services Center Questionnaire-Version B

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	NONE	National Study of Long-Term Care Providers--2016 Adult Day Services Center Questions-Version B	Att D-4_ 2016 ADSC questions Version B 031816.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: Health Resources Utilization Statistics

FR Citation: 49 FR 37697

Number of Respondents: 1,350

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 15 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,350	1,350
Annual IC Time Burden (Hours)	675	675
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.