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Local Directors/Regional Representaitves and Local Representatives
Process Evaluation and Special Studies Related to the Long-Term Care Ombudsman Program
OMB: 0985-0055
IC ID: 224905
OMB.report
HHS/ACL
OMB 0985-0055
ICR 201712-0985-001
IC 224905
( )
Documents and Forms
Document Name
Document Type
Form 1
Local Directors/Regional Representaitves and Local Representatives
Form
1 Local Director Survey
Local-Directors-Survey.doc
Form
2 Local Representatives Survey
Local-Representatives-Survey.doc
Form
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Local Directors/Regional Representaitves and Local Representatives
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Unchanged
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
Form
1
Local Director Survey
Local-Directors-Survey.doc
Yes
Yes
Fillable Fileable
Form
2
Local Representatives Survey
Local-Representatives-Survey.doc
Yes
Yes
Fillable Fileable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Community and Social Services
Subfunction:
Social Services
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
300
Number of Respondents for Small Entity:
0
Affected Public:
State, Local, and Tribal Governments
Percentage of Respondents Reporting Electronically:
0 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
300
0
0
0
0
300
Annual IC Time Burden (Hours)
175
0
0
0
0
175
Annual IC Cost Burden (Dollars)
0
0
0
0
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.
