View Information Collection (IC)

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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10409	Proposed LTCH QRP New and Modified Items	Proposed LTCH QRP Item Mockups-Effective October 1 2020.pdf		Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 415	Number of Respondents for Small Entity: 89

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

Percentage of Respondents Reporting Electronically: 100 %

	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	204,936	0	-68,016	0	0	272,952
Annual IC Time Burden (Hours)	145,831	0	24,157	0	0	121,674
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Appendix A: Change Table	Change Table for Proposed LTCH QRP Items-Effective October 1 2020.pdf	05/28/2019

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