State OMBudsman Interview Protocol and Survey

Process Evaluation and Special Studies Related to the Long-Term Care Ombudsman Program

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0985-0055 can be found here:

Documents and Forms

Document Name Document Type
Form 1 State Ombudsman Interview Protocol and Survey Form
1 State Ombudsman Interview State-Ombudsmen-Interview-Protocol.doc Form
2 State Ombudsmen Survey State-Ombudsmen-Survey.doc Form

Information Collection (IC) Details

IC Title:	State Ombudsman Interview Protocol and Survey	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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	1	State Ombudsman Interview	State-Ombudsmen-Interview-Protocol.doc		Yes	Yes	Fillable Fileable
Form	2	State Ombudsmen Survey	State-Ombudsmen-Survey.doc		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: 53	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	53	53
Annual IC Time Burden (Hours)	98	98
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.