Information Collection

Nursing Home SOPS Data File Submission

IC 201035 under ICR 202410-0935-001 · OMB 0935-0195.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Form 4 Nursing Home SOPS Data File Submission	Form and Instruction
Form Form 4 Nursing Home SOPS Data File Submission Nursing Home SOPS Data File Submission	Form and Instruction
Form 4 Nursing Home SOPS Data File Submission Attachment D - Nursing Home Data File Submission.docx	Form and Instruction
Form 4 Nursing Home SOPS Data File Submission Attachment D - Nursing Home Data File Submission.docx	Form and Instruction
Attachment K - NH Submission Home Page.docx Attachment K - NH Submission Home Page	IC Document
Attachment K - NH Submission Home Page.docx Attachment K - NH Submission Home Page	IC Document
Attachment I - Emails - NH SOPS Data Submission.doc Attachment I - Emails - NH SOPS Data Submission	IC Document
Attachment I - Emails - NH SOPS Data Submission.doc Attachment I - Emails - NH SOPS Data Submission	IC Document
Attachment L - NH Questionnaire Upload Page.docx Attachment L - NH Questionnaire Upload Page	IC Document
Attachment L - NH Questionnaire Upload Page.docx Attachment L - NH Questionnaire Upload Page	IC Document
Attachment M - NH SOPS Data Submission Specs.pdf Attachment M - NH SOPS Data Submission Specs	IC Document
Attachment M - NH SOPS Data Submission Specs.pdf Attachment M - NH SOPS Data Submission Specs	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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	Form 4				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 50

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
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	50	10	40
Annual IC Time Burden (Hours)	50	10	40
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment K - NH Submission Home Page		01/31/2012
Attachment I - Emails - NH SOPS Data Submission		01/31/2012
Attachment L - NH Questionnaire Upload Page		01/31/2012
Attachment M - NH SOPS Data Submission Specs		01/31/2012

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

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