Information Collection

Nursing Home Administrators Committee Chair Interview

IC 205003 under ICR 201808-0920-007 · OMB 0920-0914.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-0914 Nursing Home Administrators Committee Chair Interview	Form
0920-0914 Committee Chair Interview Appendix C2.doc	Form
0920-0914 Committee Chair Interview Online Appendix C2 online version.docx odu.co1.qualtrics.com/jfe/form/SV_bIRVNzuQ9y2M981	Form

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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
Form	0920-0914	Committee Chair Interview Online	Appendix C2 online version.docx	https://odu.co1.qualtrics.com/jfe/form/SV_bIRVNzuQ9y2M981	Yes	Yes	Fillable Fileable
Form	0920-0914	Committee Chair Interview	Appendix C2.doc		No		Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 20

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: 0 %

table that charts list of burden
	Requested	Previously Approved
Annual Number of Responses for this IC	20	20
Annual IC Time Burden (Hours)	20	20
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.