RCC Services User 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⚠️ Notice: This information collection may be referencing outdated material.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
RCC Services User Questionnaire Form and Instruction
RCC Services User Questionnaire Items Att C-3 RCC SU questionnaire.docx Form and Instruction
RCC Services User Questionnaire Items Att C-3 RCC SU questionnaire.docx Form and Instruction

Information Collection (IC) Details

IC Title:	RCC Services User Questionnaire	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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	RCC Services User Questionnaire Items	Att C-3 RCC SU 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: 1,045	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 50 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,045	1,045
Annual IC Time Burden (Hours)	523	523
Annual IC Cost Burden (Dollars)	29,845	29,845

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.