Information Collection

Long Term Care Data Set

IC 201171 under ICR 201706-0938-007 · OMB 0938-1163.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1163 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10409 Long Term Care Data Set	Form and Instruction
CMS-10409 LTCH Care Data Set Admissions LTCH CARE Data Set Version 4.00 - Admission.pdf	Form and Instruction
CMS-10409 LTCH Care Data Set Expired LTCH CARE Data Set Version 4.00 - Expired.pdf	Form and Instruction
CMS-10409 LTCH Care Data Set Planned Discharge LTCH CARE Data Set Version 4.00 - Planned Discharge.pdf	Form and Instruction
CMS-10409 LTCH Care Data Set Unplanned Discharge LTCH CARE Data Set Version 4.00 - Unplanned Discharge.pdf	Form and Instruction
Appendix A - Master List of LTCH CARE Data Set Version 4.00 Items.xlsx Appendix A: Master List	IC Document
Appendix B - Proposed LTCH CARE Data Set Version 4.00 Change Table - Effective April 1, 2018.pdf Appendix B: LTCH Version 4.0 Change Table	IC Document

IC Title:

Long Term Care Data Set

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10409	LTCH Care Data Set Admissions	LTCH CARE Data Set Version 4.00 - Admission.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10409	LTCH Care Data Set Expired	LTCH CARE Data Set Version 4.00 - Expired.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10409	LTCH Care Data Set Planned Discharge	LTCH CARE Data Set Version 4.00 - Planned Discharge.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10409	LTCH Care Data Set Unplanned Discharge	LTCH CARE Data Set Version 4.00 - Unplanned Discharge.pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 426

Number of Respondents for Small Entity: 112

Affected Public: Private Sector

Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	293,184	-112,086	405,270
Annual IC Time Burden (Hours)	165,884	-226,977	392,861
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Appendix A: Master List	Appendix A - Master List of LTCH CARE Data Set Version 4.00 Items.xlsx	06/28/2017
Appendix B: LTCH Version 4.0 Change Table	Appendix B - Proposed LTCH CARE Data Set Version 4.00 Change Table - Effective April 1, 2018.pdf	06/28/2017

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.