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View Information Collection (IC)
View Information Collection (IC)
IC Title:
Nursing Home National Provider Survey
Agency IC Tracking Number:
Is this a Common Form?
No
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
CMS-10551
Qualitative Interview Guide
NH Attachment III NH Qualitative Interview Guide Mapping Research to Interview 2015 11 10.docx
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10551
Structured Research Guide
NH Attachment IV NH Structured Research Questions Mapped to Survey Questions 2015 11 10.docx
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10551
Summary of Interview
NH Attachment VI Summary of Interview Content 2015 11 10.docx
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10551
List of Quality and Efficiency Measures
NH Attachment VII List of Quality Measures 2015 11 10.docx
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10551
Interview Topic Guide for Semi-Structured Interview
NH Attachment VIII Interview Topic Guide for Semi-Structured Interview 2015 11 10.docx
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10551
Standardized Hospital National Provider Survey
NH Attachment XIII Standardized Nursing Home National Provider Survey 2015 10.docx
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:
940
Number of Respondents for Small Entity:
0
Affected Public:
Private Sector
Private Sector:
Businesses or other for-profits, Not-for-profit institutions
Percentage of Respondents Reporting Electronically:
30 %
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
940
0
940
0
0
0
Annual IC Time Burden (Hours)
639
0
639
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
Llst of Attachments
Nursing Home National Provider Survey List of Attachments 2015 11 10.docx
11/16/2015
Second Survey Cover Letter
NH Attachment XII Second Survey Cover Letter 2015 11 10.docx
11/16/2015
Attachment XI - Reminder Letter
NH Attachment XI Reminder Letter 2015 11 10.docx
11/16/2015
Attachment X - First Mail Survey Letter
NH Attachment X First Mail Survey Cover Letter 2015 11 10.docx
11/16/2015
Recruitment Email
NH Attachment V Recruitment email or letter 2015 11 10.docx
11/16/2015
Attachment IX - Web Survey Invitation Emial
NH Attachment IX Web Survey Invitation Email 2015 11 10.docx
11/16/2015
Attachment I - Development of Two National Provider Surveys
NH Attachment I Development of Two National Provider Surverys 2015 11 10.docx
11/16/2015
Attachment II - Data Sources used for 2015 Impact Assessment
NH Attachment II Data Sources Used for 2015 Impact Assessment Report 2015 11 10.docx
11/16/2015
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
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