Information Collection

Long Term Care Data Set

IC 201171 under ICR 202604-0938-025 · OMB 0938-1163.

Documents and Forms

Document Name Document Type
Form CMS-10409 LCDS version 5.3 Admission Long Term Care Data Set Form and Instruction
Form CMS-10409 LCDS version 5.3 Expired Long Term Care Data Set Form and Instruction
Form CMS-10409 LCDS version 5.3 Planned Discharge Long Term Care Data Set Form and Instruction
Form CMS-10409 LCDS version 5.3 Unplanned Discharge Long Term Care Data Set Form and Instruction
CMS-10409 LCDS version 5.3 Admission LTCH-CARE-Data-Set-Version-5.3-Admission.pdf Form and Instruction
CMS-10409 LCDS version 5.3 Expired LTCH-CARE-Data-Set-Version-5.3-Expired.pdf Form and Instruction
CMS-10409 LCDS version 5.3 Planned Discharge LTCH-CARE-Data-Set-Version-5.3-Planned-DC.pdf Form and Instruction
CMS-10409 LCDS version 5.3 Unplanned Discharge LTCH-CARE-Data-Set-Version-5.3-Unplanned-DC.pdf Form and Instruction
Crosswalk_LCDS_5.3_508.pdf Crosswalk IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Long Term Care Data Set	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10409	LCDS version 5.3 Admission	LTCH-CARE-Data-Set-Version-5.3-Admission.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10409	LCDS version 5.3 Expired	LTCH-CARE-Data-Set-Version-5.3-Expired.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10409	LCDS version 5.3 Planned Discharge	LTCH-CARE-Data-Set-Version-5.3-Planned-DC.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10409	LCDS version 5.3 Unplanned Discharge	LTCH-CARE-Data-Set-Version-5.3-Unplanned-DC.pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 318	Number of Respondents for Small Entity: 89

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

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	102,590	-34,060	136,650
Annual IC Time Burden (Hours)	184,588	-513	185,101
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Crosswalk	Crosswalk_LCDS_5.3_508.pdf	05/04/2026

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

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