State Annual Long-Term Care OMBudsman Report

State Annual Long-Term Care Ombudsman Report

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0985-0005 can be found here:

Documents and Forms

Document Name Document Type
Form 1 State Annual Long-Term Care Ombudsman Report Form
3 NORS Table 3 Program Information NORS Table_3 _Program Information.pdf Form
1 NORS Table 1 Table_1_final_04-09-18.pdf Form
2 Table 2 Complaint Codes Table_2_Complaint Codes 1.pdf Form
3 NORS Table 3 Program Information Table_3 _Final_04-09-18.pdf Form

Information Collection (IC) Details

IC Title:	State Annual Long-Term Care Ombudsman Report	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 45 CFR 1321.49

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	1	NORS Table 1	Table_1_final_04-09-18.pdf	Yes	Yes	Fillable Fileable
Form	2	Table 2 Complaint Codes	Table_2_Complaint Codes 1.pdf	Yes	Yes	Fillable Fileable
Form	3	NORS Table 3 Program Information	Table_3 _Final_04-09-18.pdf	Yes	Yes	Fillable Fileable
Form	3	NORS Table 3 Program Information	NORS Table_3 _Program Information.pdf	Yes	Yes	Fillable Fileable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 52	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	52	0	52
Annual IC Time Burden (Hours)	11,628	3,874	7,754
Annual IC Cost Burden (Dollars)	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.