Information Collection

Community Living Center (CLC) Survey

IC 260348 under ICR 202503-2900-010 · OMB 2900-0876.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0876 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CLC WF with footer Community Living Center (CLC) Survey	Form and Instruction
Form CLC WF with footer CLC WF with footer & logic & priv 5.22.23 Community Living Center (CLC) Survey	Form and Instruction
CLC WF with footer CLC WF with footer & logic & priv 5.22.23 CLC WF with footer & logic & priv 5.22.23.docx	Form and Instruction
CLC WF with footer CLC WF with footer & logic & priv 5.22.23 CLC WF with footer & logic & priv 5.22.23.docx	Form and Instruction
ICR Template_A11 Section 280 Clearance CLC v2.docx ICR Template_A11 Section 280 Clearance CLC v2	IC Document
ICR Template_A11 Section 280 Clearance CLC v2.docx ICR Template_A11 Section 280 Clearance CLC v2	IC Document

IC Title:

Community Living Center (CLC) Survey

Agency IC Tracking Number:

2900-0876 Community Living Center (CLC) Survey

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 and Instruction	CLC WF with footer & logic & priv 5.22.23				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 10,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Previously Approved
Annual Number of Responses for this IC	10,000	10,000
Annual IC Time Burden (Hours)	333	333
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
ICR Template_A11 Section 280 Clearance CLC v2		05/23/2023

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

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