Information Collection

57.142 Denominators for LTCF Locations

IC 200379 under ICR 202408-0920-016 · OMB 0920-0666.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0666 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CDC 57.142 57.142 Denominators for LTCF Locations	Form
CDC 57.142 Denominators for LTCF 57.142_DenominatorLTCF_ update for RP module_clean.docx	Form
CDC 57.142 Denominators for LTCF 57.142_DenominatorLTCF_ update for RP module_clean.docx	Form

IC Title:

57.142 Denominators for LTCF Locations

Agency IC Tracking Number:

0920-0666

Is this a Common Form? No

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	CDC 57.142	Denominators for LTCF	57.142_DenominatorLTCF_ update for RP module_clean.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 715

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: 100 %

table that charts list of burden
	Requested	Previously Approved
Annual Number of Responses for this IC	8,580	8,580
Annual IC Time Burden (Hours)	5,005	5,005
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.