Information Collection

Long Term Care Data Set

IC 201171 under ICR 202111-0938-016 · OMB 0938-1163.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1163 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10409 Long Term Care Data Set	Form and Instruction
CMS-10409 LCDS version 5.00 Admission LTCH CARE Data Set Version 5.00 - Admission_final_submission.pdf	Form and Instruction
CMS-10409 LCDS version 5.00 Admission LTCH CARE Data Set Version 5.00 - Admission_final_submission.pdf	Form and Instruction
CMS-10409 LCDS version 5.00 Expired LTCH CARE Data Set Version 5.00 - Expired_final_submission.pdf	Form and Instruction
CMS-10409 LCDS version 5.00 Expired LTCH CARE Data Set Version 5.00 - Expired_final_submission.pdf	Form and Instruction
CMS-10409 LCDS version 5.00 Planned Discharge LTCH CARE Data Set Version 5.00 - Planned Discharge_final_submission.pdf	Form and Instruction
CMS-10409 LCDS version 5.00 Planned Discharge LTCH CARE Data Set Version 5.00 - Planned Discharge_final_submission.pdf	Form and Instruction
CMS-10409 LCDS version 5.00 Unplanned Discharge LTCH CARE Data Set Version 5.00 - Unplanned Discharge_final_submission.pdf	Form and Instruction
CMS-10409 LCDS version 5.00 Unplanned Discharge LTCH CARE Data Set Version 5.00 - Unplanned Discharge_final_submission.pdf	Form and Instruction

IC Title:

Long Term Care Data Set

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10409	LCDS version 5.00 Admission	LTCH CARE Data Set Version 5.00 - Admission_final_submission.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10409	LCDS version 5.00 Expired	LTCH CARE Data Set Version 5.00 - Expired_final_submission.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10409	LCDS version 5.00 Planned Discharge	LTCH CARE Data Set Version 5.00 - Planned Discharge_final_submission.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10409	LCDS version 5.00 Unplanned Discharge	LTCH CARE Data Set Version 5.00 - Unplanned Discharge_final_submission.pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 415

Number of Respondents for Small Entity: 89

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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	204,936	-68,016	272,952
Annual IC Time Burden (Hours)	145,831	24,157	121,674
Annual IC Cost Burden (Dollars)	0	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.