Information Collection

Long Term Care Data Set

IC 201171 under ICR 202406-0938-002 · OMB 0938-1163.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1163 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10409 Long Term Care Data Set Form and Instruction
CMS-10409 LCDS version 5.1 Admission LTCH-CARE-Data-Set-Version-5.2-Admission-v6.pdf Form and Instruction
CMS-10409 LCDS version 5.1 Admission LTCH-CARE-Data-Set-Version-5.2-Admission-v6.pdf Form and Instruction
CMS-10409 LCDS version 5.1 Expired LTCH-CARE-Data-Set-Version-5.2-Expired-v3.pdf Form and Instruction
CMS-10409 LCDS version 5.1 Expired LTCH-CARE-Data-Set-Version-5.2-Expired-v3.pdf Form and Instruction
CMS-10409 LCDS version 5.1 Planned Discharge LTCH-CARE-Data-Set-Version-5.2-Planned-Discharge-v5.pdf Form and Instruction
CMS-10409 LCDS version 5.1 Planned Discharge LTCH-CARE-Data-Set-Version-5.2-Planned-Discharge-v5.pdf Form and Instruction
CMS-10409 LCDS version 5.1 Unplanned Discharge LTCH-CARE-Data-Set-Version-5.2-Unplanned-Discharge-v3.pdf Form and Instruction
CMS-10409 LCDS version 5.1 Unplanned Discharge LTCH-CARE-Data-Set-Version-5.2-Unplanned-Discharge-v3.pdf Form and Instruction
CMS-10409 Social Determinants of Health Section R_SDOH Complete+FINAL.docx Form and Instruction
CMS-10409 Social Determinants of Health Section R_SDOH Complete+FINAL.docx Form and Instruction
Crosswalk-LCDS-5.1-to-5.2_v3.docx Crosswalk IC Document
Crosswalk-LCDS-5.1-to-5.2_v3.docx Crosswalk IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Long Term Care Data Set	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10409	LCDS version 5.1 Admission	LTCH-CARE-Data-Set-Version-5.2-Admission-v6.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10409	LCDS version 5.1 Expired	LTCH-CARE-Data-Set-Version-5.2-Expired-v3.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10409	LCDS version 5.1 Planned Discharge	LTCH-CARE-Data-Set-Version-5.2-Planned-Discharge-v5.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10409	LCDS version 5.1 Unplanned Discharge	LTCH-CARE-Data-Set-Version-5.2-Unplanned-Discharge-v3.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10409	Social Determinants of Health	Section R_SDOH Complete+FINAL.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 329	Number of Respondents for Small Entity: 89

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

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	226,940	-70,113	297,053
Annual IC Time Burden (Hours)	187,735	-23,646	211,381
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Crosswalk	Crosswalk-LCDS-5.1-to-5.2_v3.docx	06/14/2024

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