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⚠️ Notice: This information collection may be referencing outdated material.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

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

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.