Information Collection

LTCF Resident Impact and Facility Capacity - LTCF personnel

IC 241490 under ICR 202008-0920-012 · OMB 0920-1290.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
LTCF Resident Impact and Facility Capacity - LTCF personnel	Form
Resident impact and facility capacity CDC 57.144_COVID-19 form_Resident Impact and Facility Capacity_v3_Ready for DEV 7.23.20.docx	Form
0920-1290 LTCF Resident Impact and Facitlity Capacity POC - 26AUG2 CDC 57.144_COVID-19_Resident Impact and Facility Capacity POC 20AUG2020.docx	Form and Instruction
CDC 57.144_TOI_Resident Impact and Facility Capacity POC 20AUG2020.docx Instructions - LTCF Resident Impact and Facitlity Capacity	IC Document

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	none	Resident impact and facility capacity	CDC 57.144_COVID-19 form_Resident Impact and Facility Capacity_v3_Ready for DEV 7.23.20.docx		Yes	Yes	Fillable Fileable
Form and Instruction	0920-1290	LTCF Resident Impact and Facitlity Capacity POC - 26AUG2020	CDC 57.144_COVID-19_Resident Impact and Facility Capacity POC 20AUG2020.docx	NA	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 9,782

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	254,332	0	254,332
Annual IC Time Burden (Hours)	169,555	21,195	148,360
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Instructions - LTCF Resident Impact and Facitlity Capacity	CDC 57.144_TOI_Resident Impact and Facility Capacity POC 20AUG2020.docx	08/26/2020

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