Nursing Home Site Information Form

Nursing Home Survey on Patient Safety Culture Comparative Database

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0935-0195 can be found here:

Documents and Forms

Document Name Document Type
Form Form #3 Nursing Home Site Information Form Form
Form #3 Nursing Home Site Information Form Attachment C - Nursing Home Site Information Form.docx Form
Form #3 Nursing Home Site Information Form Attachment C - Nursing Home Site Information Form.docx Form

Information Collection (IC) Details

IC Title:	Nursing Home Site Information Form	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	Form #3	Nursing Home Site Information Form	Attachment C - Nursing Home Site Information Form.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 40	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 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	200	-100	300
Annual IC Time Burden (Hours)	17	-8	25
Annual IC Cost Burden (Dollars)	0	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.