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Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
Collaborating Center for Questionnaire Design and Evaluation Research (CCQDER)
Agency IC Tracking Number:
0920-0222 (18AGM)
IC Status:
New
Obligation to Respond:
Voluntary
CFR Citation:
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form and Instruction
0920-0222
National Study of Long-Term Care Provider 2016 Adult Day Services Center Questionnaire
Attach 1a - ADSC Questionnaire-v2 051418.pdf
No
Fillable Fileable
Form and Instruction
0920-0222
National Study of Long-Term Care Providers 2016 Residential Care Community Questionnaire
Attach 1b - RCC Questionnaire-v2 051418.pdf
No
Fillable Fileable
Form and Instruction
0920-0222
Adult Day Care Services Center (ADSC) Telephone Screening Script
Attach 3a - ADSC Telephone Screener.docx
No
Fillable Fileable
Form and Instruction
0920-0222
Residential Care Community (RCC) Telephone Screening Script
Attach 3b - RCC Telephone Screener.docx
No
Fillable Fileable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Public Health Monitoring
Privacy Act System of Records
Title:
Health and Demongraphic Surveys Conducted in Probability Samples of the U.S. Population
FR Citation:
49 FR 37693
Number of Respondents:
112
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
0 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
112
0
112
0
0
0
Annual IC Time Burden (Hours)
46
0
46
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
LTCSB 10-day Letter
LTCSB10-day letter 051418.docx
05/17/2018
Att 2_Advance Letter
Attach 2 - Advance Letter.docx
05/17/2018
Att 4_Informed Consent
Attach 4 - Informed Consent.doc
05/17/2018
Att 5_Resp Data Collect Sheet
Attach 5 - Resp Data Collect Sheet.doc
05/17/2018
Att 6_Thank you Letter
Attach 6 - Thank you letter.doc
05/17/2018
Att 7_Special Consent
Attach 7 - Special Consent.docx
05/17/2018
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.