Information Collection

Alzheimer's Disease Supportive Services Program (ADSSP) Data Collection

IC 178976 under ICR 202310-0985-003 · OMB 0985-0022.

Documents and Forms

Document Name Document Type
Alzheimer's Disease Supportive Services Program (ADSSP) Data Collection Form and Instruction
0022 PRA Public Burden Statement.pdf Other-PRA PBS
0022 PRA Public Burden Statement.pdf Other-PRA PBS
ADSSP Excel Tool 0022 Final Ins.xlsx Form and Instruction
ADSSP Excel Tool 0022 Final Ins.xlsx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Alzheimer's Disease Supportive Services Program (ADSSP) Data Collection	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

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	NA	ADSSP Excel Tool	0022 Final Ins.xlsx		Yes	Yes	Fillable Fileable
Other-PRA PBS			0022 PRA Public Burden Statement.pdf		Yes	Yes	Fillable Fileable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 69	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	138	-402	540
Annual IC Time Burden (Hours)	916	-1,413	2,329
Annual IC Cost Burden (Dollars)	0	0	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.