Information Collection

57.143 Prevention Process Measures Monthly Monitoring for LTCF

IC 200380 under ICR 202010-0920-016 · 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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
Document Name	Document Type
Form CDC 57.143 57.143 Prevention Process Measures Monthly Monitoring for LTCF	Form
CDC 57.143 Prevention Process Measures Monthly Monitoring 57.143_ProcessMeasureSummaryforLTCF_BLANK.DOCX	Form
G14. LTCF Prevention Process Measures.pdf Att G14_LTCF Prevention Process Measures	IC Document

IC Title:

57.143 Prevention Process Measures Monthly Monitoring for LTCF

Agency IC Tracking Number:

0920-0666

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	CDC 57.143	Prevention Process Measures Monthly Monitoring	57.143_ProcessMeasureSummaryforLTCF_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: 130

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

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

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	1,560	-2,940	4,500
Annual IC Time Burden (Hours)	312	-63	375
Annual IC Cost Burden (Dollars)	5,156	-9,717	14,873

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Att G14_LTCF Prevention Process Measures	G14. LTCF Prevention Process Measures.pdf	08/08/2016

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