ADSC Provider Questionnaire

Data Collection for the Residential Care Community and Adult Day Services Center Components of the National Study of Long-term Care Providers

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0943 can be found here:

Documents and Forms

Document Name Document Type
Form 0920-0943 ADSC Provider Questionnaire Form and Instruction
0920-0943 ADSC Provider Questionnaire Att C-2 ADSC Questionnaire.docx Form and Instruction

Information Collection (IC) Details

IC Title:	ADSC Provider Questionnaire	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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	0920-0943	ADSC Provider Questionnaire	Att C-2 ADSC Questionnaire.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: Health Resources Utilization Statistics	FR Citation: 49 FR 37697

Number of Respondents: 2,750	Number of Respondents for Small Entity: 770

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

Percentage of Respondents Reporting Electronically: 30 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	2,750	2,750
Annual IC Time Burden (Hours)	1,375	1,375
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.