Information Collection

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

IC 275349 under ICR 202507-0920-001 · 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⚠️ Notice: This information collection may be referencing outdated material.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
[NCEZID] In-Depth Interviews about Infection Prevention and Control Practices in Long-Term Care Facilities	Form and Instruction
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
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: 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
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 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 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
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_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 A_4.16.25.docx SSA	IC Document
DHQP_OMB Supporting Statement B_4.16.25.docx SSB	IC Document
DHQP_OMB Supporting Statement B_4.16.25.docx SSB	IC Document

Information Collection (IC) Details

View Information Collection (IC)

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: Unchanged

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

Federal Enterprise Architecture Business Reference Module

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
	Requested	Previously Approved
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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