Information Collection

Standard of Care Survey

IC 220450 under ICR 201702-0920-002 · OMB 0920-1133.

Documents and Forms

Documents and forms in this information collection
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
Philadelphia Standard of Care Survey (modified February Att10_PA_Stand_of_Care_02102017.docx	Form

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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	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	Philadelphia Standard of Care Survey (modified February 2017)	Att10_PA_Stand_of_Care_02102017.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 %

table that charts list of burden
	Approved	Previously Approved
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

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.