Information Collection

Long Term Care Data Set

IC 201171 under ICR 201905-0938-012 · OMB 0938-1163.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1163 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10409 Long Term Care Data Set	Form and Instruction
CMS-10409 Proposed LTCH QRP New and Modified Items Proposed LTCH QRP Item Mockups-Effective October 1 2020.pdf	Form and Instruction
Change Table for Proposed LTCH QRP Items-Effective October 1 2020.pdf Appendix A: Change Table	IC Document

IC Title:

Long Term Care Data Set

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 and Instruction	CMS-10409	Proposed LTCH QRP New and Modified Items	Proposed LTCH QRP Item Mockups-Effective October 1 2020.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 415

Number of Respondents for Small Entity: 89

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	204,936	-68,016	272,952
Annual IC Time Burden (Hours)	145,665	23,991	121,674
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Appendix A: Change Table	Change Table for Proposed LTCH QRP Items-Effective October 1 2020.pdf	05/28/2019

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