Information Collection

Community Nursing Home (CNH) Dementia ECHO: Staff Education Evaluation

IC 235759 under ICR 201710-2900-001 · OMB 2900-0770.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0770 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
CNH Dementia ECHO Staff Education Questionnaire_Final_April 2019.docx	Other-Questionnaire
CNH Dementia ECHO Staff Education Questionnaire_OMB passback revisions_July 2019_Final.docx	Other-Questionnaire
Generic Clearance Submission Template_Final_May 2019.doc Generic Clearance Statement_CNH Dementia ECHO Educ_May 2019	IC Document
Dementia ECHO_Generic Clearance Statement_OMB passback revisions_July 2019_Final.doc Generic Clearance Supporting Statement	IC Document

IC Title:

Community Nursing Home (CNH) Dementia ECHO: Staff Education Evaluation

Agency IC Tracking Number:

2900-0770

IC Status: New

Obligation to Respond: Voluntary

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
Other-Questionnaire			CNH Dementia ECHO Staff Education Questionnaire_OMB passback revisions_July 2019_Final.docx		No		Paper Only
Other-Questionnaire			CNH Dementia ECHO Staff Education Questionnaire_Final_April 2019.docx		No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 150

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	150	150
Annual IC Time Burden (Hours)	25	25
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Generic Clearance Statement_CNH Dementia ECHO Educ_May 2019	Generic Clearance Submission Template_Final_May 2019.doc	05/23/2019
Generic Clearance Supporting Statement	Dementia ECHO_Generic Clearance Statement_OMB passback revisions_July 2019_Final.doc	07/30/2019

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