Information Collection

State Annual Long-Term Care OMBudsman Report

IC 10249 under ICR 202404-0985-004 · OMB 0985-0005.

Documents and Forms

Document Name Document Type
State Annual Long-Term Care Ombudsman Report Form and Instruction
NORS Table 1 0005 NORS Table 1 Case Level 2024 Ext.pdf Form and Instruction
NORS Table 2 0005 NORS Table 2 Complaint Code 2024 Ext.pdf Form and Instruction
NORS Table 3 0005 NORS Table 3 Program Information 2024 Ext.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	State Annual Long-Term Care Ombudsman Report	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 45 CFR 1321.49

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	NA	NORS Table 1	0005 NORS Table 1 Case Level 2024 Ext.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	NA	NORS Table 2	0005 NORS Table 2 Complaint Code 2024 Ext.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	NA	NORS Table 3	0005 NORS Table 3 Program Information 2024 Ext.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: 52	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Previously Approved
Annual Number of Responses for this IC	52	52
Annual IC Time Burden (Hours)	11,153	11,153
Annual IC Cost Burden (Dollars)	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.