Information Collection

[NCEZID] In-Depth Interviews about Infection Prevention and Control Practices in Long-Term Care Facilities

IC 275349 under ICR 202503-0920-028 · OMB 0920-1154.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1154 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
DHQP Interview Screener [NCEZID] In-Depth Interviews about Infection Prevention and Control Practices in Long-Term Care Facilities	Form and Instruction
Interview Guide: Resident and Family/Close Friend (Paired Interview) [NCEZID] In-Depth Interviews about Infection Prevention and Control Practices in Long-Term Care Facilities	Form and Instruction
Interview Guide: Family/Close Friend (Follow-Up Interview) [NCEZID] In-Depth Interviews about Infection Prevention and Control Practices in Long-Term Care Facilities	Form and Instruction
DHQP Interview Screener Attachment 1_DHQP_Screener_4.16.25.docx	Form and Instruction
Interview Guide: Resident and Family/Close Friend (Paire Attachment 4_DHQP_Resident and Family Guide_3.25.25_Final.docx	Form and Instruction
Interview Guide: Family/Close Friend (Follow-Up Intervie Attachment 5_DHQP_Family Follow-Up Guide_4.16.25.docx	Form and Instruction
Attachment 2_DHQP_Consent Form_Resident_4.16.25.docx Consent Form Resident	IC Document
Attachment 3_DHQP_Consent Form_Family or Friend_4.16.25.docx Consent Form Family or Friend	IC Document
Attachment 6_Human Subjects Determination Memo.pdf Research Determination	IC Document
DHQP_Gen IC Request Form_4.16.25.docx GenIC Request Template	IC Document
DHQP_OMB Supporting Statement A_4.16.25.docx SSA	IC Document
DHQP_OMB Supporting Statement B_4.16.25.docx SSB	IC Document

IC Title:

[NCEZID] In-Depth Interviews about Infection Prevention and Control Practices in Long-Term Care Facilities

Agency IC Tracking Number:

0920-25-0100

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	n/a	Yes	Yes	Fillable Fileable
Form and Instruction	n/a	Yes	Yes	Fillable Fileable
Form and Instruction	n/a	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 234

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 90 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	234	234
Annual IC Time Burden (Hours)	63	63
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Consent Form Resident		05/20/2025
Consent Form Family or Friend		05/20/2025
Research Determination		05/21/2025
GenIC Request Template		05/21/2025
SSA		05/21/2025
SSB		05/21/2025

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

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