Information Collection

57.136 Long Term Care Facility Component - Respiratory Tract Infection

IC 238093 under ICR 201908-0920-004 · OMB 0920-0666.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0666 can be found here:

Documents and Forms

Document Name Document Type
Form 57.136 57.136 Long Term Care Facility Component - Respiratory Tract Infection Form and Instruction
57.136 Long-Term Care Facility Component – Respiratory Tract In 57.136_RTI_LTCF_BLANK.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	57.136 Long Term Care Facility Component - Respiratory Tract Infection	Agency IC Tracking Number:	0920-0666

Is this a Common Form? No		IC Status: New

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 and Instruction	57.136	Long-Term Care Facility Component â Respiratory Tract Infection	57.136_RTI_LTCF_BLANK.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 400	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
Annual Number of Responses for this IC	4,800	4,800
Annual IC Time Burden (Hours)	2,400	2,400
Annual IC Cost Burden (Dollars)	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.