Information Collection

Structural Assessments – Cohorts 1, 2 and 3 (baseline, post-intervention)

IC 227697 under ICR 201707-0935-003 · OMB 0935-0238.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0935-0238 can be found here:

Documents and Forms

Document Name Document Type
Form a1 Structural Asse Structural Assessments – Cohorts 1, 2 and 3 (baseline, post-intervention) Form and Instruction
a1 Structural Asse Attachment A: Structural Assessment for Acute Care Setti Att A Structural Assessment for the Acute Care Setting.docx Form and Instruction
a2 Structural Asse a2 Structural Assessments – Cohorts 1, 2 and 3 Att B Structural Assessment for the Ambulatory Care Setting.docx Form and Instruction
a3 Structural Asse Attachment C: Structural Assessment for Long Term Care S Att C Structural Assessment for the Long-Term Care Setting.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Structural Assessments â Cohorts 1, 2 and 3 (baseline, post-intervention)	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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	a1 Structural Assessments â Cohorts 1, 2 and 3	Attachment A: Structural Assessment for Acute Care Setting	Att A Structural Assessment for the Acute Care Setting.docx	Yes	Yes	Fillable Fileable
Form and Instruction	a2 Structural Assessments â Cohorts 1, 2 and 3	a2 Structural Assessments â Cohorts 1, 2 and 3	Att B Structural Assessment for the Ambulatory Care Setting.docx	Yes	Yes	Fillable Fileable
Form and Instruction	a3 Structural Assessments â Cohorts 1, 2 and 3	Attachment C: Structural Assessment for Long Term Care Setting	Att C Structural Assessment for the Long-Term Care Setting.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 343	Number of Respondents for Small Entity: 0

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

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	686	686
Annual IC Time Burden (Hours)	137	137
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.