Information Collection

Exhibit S (Resident FTE Assessment)

IC 211283 under ICR 201612-0915-004 · OMB 0915-0247.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0247 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Exhibit S (Residen Exhibit S (Resident FTE Assessment)	Form
Exhibit S (Residen Exhibit S (Resident FTE Assessment) CHGME_Exhibit S (Resident FTE Assessment).docx	Form

IC Title:

Exhibit S (Resident FTE Assessment)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

Obligation to Respond: Required to Obtain or Retain Benefits

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	Exhibit S (Resident FTE Assessment)	Exhibit S (Resident FTE Assessment)	CHGME_Exhibit S (Resident FTE Assessment).docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 30

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	30	30
Annual IC Time Burden (Hours)	110	110
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.