ADSC Provider Questionnaire

Data Collection for the Residential Care Community and Adult Day Services Center Components of the National Post-acute and Long-term Care Study

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0943 can be found here:

Documents and Forms

Document Name Document Type
ADSC Provider Questionnaire Form and Instruction
NPALS 2022 Adult Day Services Center Questionnaire Att C-2 ADSC provider questionnaire.docx Form and Instruction
NPALS 2022 Adult Day Services Center Questionnaire Att C-2 ADSC provider questionnaire.docx Form and Instruction

Information Collection (IC) Details

IC Title:	ADSC Provider Questionnaire	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 and Instruction	None	NPALS 2022 Adult Day Services Center Questionnaire	Att C-2 ADSC provider questionnaire.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: Health Resources Utilization Statistics	FR Citation: 49 FR 37697

Number of Respondents: 875	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: 50 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	875	-1,875	2,750
Annual IC Time Burden (Hours)	438	-937	1,375
Annual IC Cost Burden (Dollars)	24,990	24,990	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.