Information Collection

State Annual Long-Term Care OMBudsman Report

IC 10249 under ICR 202108-0985-001 · OMB 0985-0005.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0985-0005 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
State Annual Long-Term Care Ombudsman Report	Form and Instruction
Table 1 NORS Table 1 Case Level 07-09-2021.pdf	Form and Instruction
Table 1 NORS Table 1 Case Level 07-09-2021.pdf	Form and Instruction
Table 2 NORS Table 2 Complaint Code 07-09-2021.pdf	Form and Instruction
Table 2 NORS Table 2 Complaint Code 07-09-2021.pdf	Form and Instruction
Table 3 NORS Table 3 Program Information 07-09-2021.pdf	Form and Instruction
Table 3 NORS Table 3 Program Information 07-09-2021.pdf	Form and Instruction

IC Title:

State Annual Long-Term Care Ombudsman Report

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 45 CFR 1321.49

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	NA	Table 1	NORS Table 1 Case Level 07-09-2021.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	NA	Table 2	NORS Table 2 Complaint Code 07-09-2021.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	NA	Table 3	NORS Table 3 Program Information 07-09-2021.pdf	Yes	Yes	Fillable Fileable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 52

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	52	52
Annual IC Time Burden (Hours)	11,153	11,153
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.