Information Collection

57.137 Long Term care Facility Component--Annual Facility Survey

IC 197541 under ICR 202603-0920-006 · OMB 0920-0666.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CDC 57.137 Long-Term Care Facility Component -- Annual Facility Survey 57.137 Long Term care Facility Component--Annual Facility Survey	Form
CDC 57.137 Long-Term Care Facility Component -- Annual Facility Sur 57.137 LTCF Annual Survey-Clean Version.docx	Form

IC Title:

Agency IC Tracking Number:

0920-0666

Is this a Common Form? No

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	CDC 57.137				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 6,270

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Previously Approved
Annual Number of Responses for this IC	6,270	6,270
Annual IC Time Burden (Hours)	14,108	14,108
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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