ADSC 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

Documents and Forms

Document Name Document Type
ADSC Services User Questionnaire Form and Instruction
ADSC Services User Questionnaire Items Att C-4 ADSC SU questionnaire.docx Form and Instruction
ADSC Services User Questionnaire Items Att C-4 ADSC SU questionnaire.docx Form and Instruction

Information Collection (IC) Details

IC Title:	ADSC 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	ADSC Services User Questionnaire Items	Att C-4 ADSC 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: 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
Annual Number of Responses for this IC	875	875
Annual IC Time Burden (Hours)	438	438
Annual IC Cost Burden (Dollars)	24,990	24,990

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.