Information Collection

ADSC Provider Questionnaire

IC 231011 under ICR 202504-0920-018 · OMB 0920-0943.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
ADSC Provider Questionnaire	Form and Instruction
2024 Adult Day Services Center Questionnaire ADSC Provider Questionnaire	Form and Instruction
Form 0920-25-0097 0920-0943 NPALS_ADSC_Final_Updated ADSC Provider Questionnaire	Form
2024 Adult Day Services Center Questionnaire Att C-2 ADSC questionnaire 0524.docx	Form and Instruction
2024 Adult Day Services Center Questionnaire Att C-2 ADSC questionnaire 0524.docx	Form and Instruction
0920-25-0097 0920-0943 NPALS_ADSC_Final_Updated 0920-0943 NPALS_ADSC_Final_Updated TEXT VERSION.docx	Form
0920-25-0097 0920-0943 NPALS_ADSC_Final_Updated 0920-0943 NPALS_ADSC_Final_Updated TEXT VERSION.docx	Form

IC Title:

Agency IC Tracking Number:

0920-25-0097

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	None				Yes	Yes	Fillable Fileable
Form	0920-25-0097				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: Health Resources Utilization Statistics

FR Citation: 49 FR 37697

Number of Respondents: 2,750

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: 50 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	2,750	2,750
Annual IC Time Burden (Hours)	1,375	1,375
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.

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