Information Collection

TEAM CHECK-UP TOOL – Long-Term Care (LTC)

IC 248495 under ICR 202107-0935-003 · OMB 0935-0260.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0935-0260 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 8 TEAM CHECK-UP TOOL – Long-Term Care (LTC)	Form and Instruction
8 Attachment G: LTC Team Checkup Tool Att G LTC Team Checkup Tool.docx	Form and Instruction
8 Attachment G: LTC Team Checkup Tool Att G LTC Team Checkup Tool.docx	Form and Instruction

IC Title:

TEAM CHECK-UP TOOL â Long-Term Care (LTC)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

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 and Instruction	8	Attachment G: LTC Team Checkup Tool	Att G LTC Team Checkup Tool.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 100

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	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,800	1,800
Annual IC Time Burden (Hours)	306	306
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.