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ADSC Provider Questionnaire
Data Collection for the Residential Care Community and Adult Day Services Center Components of the National Study of Long-term Care Providers
OMB: 0920-0943
IC ID: 231011
OMB.report
HHS/CDC
OMB 0920-0943
ICR 202007-0920-018
IC 231011
( )
⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0943 can be found here:
2024-07-31 - Revision of a currently approved collection
2022-06-08 - Revision of a currently approved collection
Documents and Forms
Document Name
Document Type
Form 0920-0943
ADSC Provider Questionnaire
Form and Instruction
0920-0943 ADSC Provider Questionnaire
Att C-2 ADSC Questionnaire.docx
Form and Instruction
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
ADSC Provider Questionnaire
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
0920-0943
ADSC Provider Questionnaire
Att C-2 ADSC Questionnaire.docx
Yes
Yes
Fillable Fileable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Public Health Monitoring
Privacy Act System of Records
Title:
Health Resources Utilization Statistics
FR Citation:
49 FR 37697
Number of Respondents:
2,750
Number of Respondents for Small Entity:
770
Affected Public:
Private Sector
Private Sector:
Not-for-profit institutions, Businesses or other for-profits
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
2,750
0
2,750
0
0
0
Annual IC Time Burden (Hours)
1,375
0
1,375
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
No associated records found
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.