Nursing Home Site Information Form

Nursing Home Survey on Patient Safety Culture Comparative Database

Documents and Forms

Document Name Document Type
Form Form 3 Nursing Home Site Information Form Form and Instruction
Form 3 Nursing Home Site Information Form Attachment C - Nursing Home Site Information Form.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Nursing Home Site Information Form	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	Form 3	Nursing Home Site Information Form	Attachment C - Nursing Home Site Information Form.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 50	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: 100 %

	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	250	50	200
Annual IC Time Burden (Hours)	21	4	17
Annual IC Cost Burden (Dollars)	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.