Information Collection

Structural Assessments – Cohorts 1, 2 and 3 (baseline, post-intervention)

IC 227697 under ICR 201906-0935-002 · OMB 0935-0238.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form a3 Structural Asse Structural Assessments – Cohorts 1, 2 and 3 (baseline, post-intervention)	Form and Instruction
a1 Structural Asse Attachment A: Structural Assessment for Acute Care Setti Attachment A Structural Assessment for the Acute Care Setting.1.docx	Form and Instruction
a2 Structural Asse a2 Structural Assessments – Cohorts 1, 2 and 3 Attachment B Structural Assessment for Ambulatory Care.1.docx	Form and Instruction
a3 Structural Asse Attachment C: Structural Assessment for Long Term Care S Attachment C Structural Assessment for the Long-Term Care Setting.1.docx	Form and Instruction

IC Title:

Structural Assessments â Cohorts 1, 2 and 3 (baseline, post-intervention)

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	a3 Structural Assessments â Cohorts 1, 2 and 3	Attachment C: Structural Assessment for Long Term Care Setting	Attachment C Structural Assessment for the Long-Term Care Setting.1.docx	Yes	Yes	Fillable Fileable
Form and Instruction	a2 Structural Assessments â Cohorts 1, 2 and 3	a2 Structural Assessments â Cohorts 1, 2 and 3	Attachment B Structural Assessment for Ambulatory Care.1.docx	Yes	Yes	Fillable Fileable
Form and Instruction	a1 Structural Assessments â Cohorts 1, 2 and 3	Attachment A: Structural Assessment for Acute Care Setting	Attachment A Structural Assessment for the Acute Care Setting.1.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 343

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: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	686	686
Annual IC Time Burden (Hours)	137	137
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.