Information Collection

ECHO National Nursing Home COVID-19 Action Network Customer Satisfaction Survey

IC 246687 under ICR 202310-0935-001 · OMB 0935-0179.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0935-0179 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 ECHO National Nursing Home COVID-19 Action Network Customer Satisfaction Survey	Form and Instruction
1 Appendix A Appendix A AHRQ ECHO National Nursing Home Initiative 04-06-2021 Revised.docx	Form and Instruction
1 Appendix A Appendix A AHRQ ECHO National Nursing Home Initiative 04-06-2021 Revised.docx	Form and Instruction
OMB Cover Letter.docx Cover Letter	IC Document
OMB Cover Letter.docx Cover Letter	IC Document
Supporting Statment A 04012021 eb 04-06-2021 po clean.docx Supporting Statement	IC Document
Supporting Statment A 04012021 eb 04-06-2021 po clean.docx Supporting Statement	IC Document
Appendix A AHRQ ECHO National Nursing Home Initiative 04-06-2021.docx Appendix A	IC Document
Appendix A AHRQ ECHO National Nursing Home Initiative 04-06-2021.docx Appendix A	IC Document

IC Title:

ECHO National Nursing Home COVID-19 Action Network Customer Satisfaction Survey

Agency IC Tracking Number:

IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1	Appendix A	Appendix A AHRQ ECHO National Nursing Home Initiative 04-06-2021 Revised.docx		No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 4,571

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: 0 %

table that charts list of burden
	Requested	Previously Approved
Annual Number of Responses for this IC	4,571	4,571
Annual IC Time Burden (Hours)	505	505
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Cover Letter	OMB Cover Letter.docx	04/06/2021
Supporting Statement	Supporting Statment A 04012021 eb 04-06-2021 po clean.docx	04/06/2021
Appendix A	Appendix A AHRQ ECHO National Nursing Home Initiative 04-06-2021.docx	04/06/2021

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.