Data Collection for the Residential Care Community and Adult Day Services Center Components of the National Study of Long-term Care Providers

Forms and Documents

Document Name	Status
Data Retrieval Telephone Call Questionnaire Form	New
Adult Day Services Center Questionnaire Form	New
Residential Care Community Questionnaire Form	New
NSLTCP DC Supp State Part B 5-8.doc Supporting Statement B	2012-06-11
Attachment H-Chain outreach package 5-8.pdf Supplementary Document	2012-06-13
Attachment G-Base Resp Contact Materials 5-8.pdf Supplementary Document	2012-06-13
Attachment M -Exp 3 Resp Contact Materials 5-8.doc Supplementary Document	2012-06-11
Attachment L -Exp 2 Resp Contact Materials 5-8.doc Supplementary Document	2012-06-11
Attachment K -Exp 1 Resp Contact Materials 5-8.doc Supplementary Document	2012-06-11
Attachment J CATI FAQs 5-24 comments.docx Supplementary Document	2012-06-11
Attachment F -Human Subjects Determination 5-8.doc Supplementary Document	2012-06-11
Attachment E Workgroup Participants 5-7.docx Supplementary Document	2012-06-11
Attachment D-Federal Register Notice 5-8.doc Supplementary Document	2012-06-11
Attachment A -NCHS Legislation 5-8.doc Supplementary Document	2012-06-11
NSLTCP DC Supp State Part A 7-25.doc Supporting Statement A	2012-07-30

IC Document Collections

IC ID	Document Title	Status
202805	Data Retrieval Telephone Call Questionnaire Form	New
202804	Adult Day Services Center Questionnaire Form	New
202803	Residential Care Community Questionnaire Form	New

ICR Details

OMB Control No: 0920-0943	ICR Reference No: 201206-0920-004
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CDC	Agency Tracking No:
Title: Data Collection for the Residential Care Community and Adult Day Services Center Components of the National Study of Long-term Care Providers
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 07/30/2012
	Date Received in OIRA: 06/20/2012
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2015	12 Months From Approved
Responses	18,371	0	0
Time Burden (Hours)	8,769	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: NCHS seeks approval to collect data for the residential care community (RCC) and adult day services center (ADSC) components of a new study, the National Study of Long-Term Care Providers (NSLTCP). Data from RCCs and ADSCs include basic characteristics, services offered, staffing, and practices of providers, and distributions of the demographics, physical functioning, and cognitive functioning of users (RCC residents and ADSC participants) aggregated to the RCC/ADSC level. The study will be administered by mail, web, and telephone to a sample of 11,701 RCCs and a census of 5,000 ADSCs in the 50 states and the District of Columbia.

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Authorizing Statute(s): US Code: 42 USC 242k Name of Law: Public Health Service Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 78261	12/16/2011
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 33745	06/07/2012
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 3

IC Title	Form No.	Form Name
Residential Care Community Questionnaire	none	RCC Questionnaire Items
Adult Day Services Center Questionnaire	none	ADSC Questionnaire Items
Data Retrieval Telephone Call Questionnaire	none	Data Retrieval Telephone Call

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	18,371	0	0	18,371	0	0
Annual Time Burden (Hours)	8,769	0	0	8,769	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This is a new ICR.

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Annual Cost to Federal Government: $1,903,248

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 06/20/2012

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