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Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
2016 CDC Healthcare Systems Scorecard (HSSC) Assessment Tool for Primary Care Practices
Agency IC Tracking Number:
16ADZ
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
none
Screener
Att 3 Screener 040616.docx
Yes
Yes
Fillable Fileable
Form
none
Interview Questionnaire
Att 1 Questionnaire 040616.doc
Yes
Yes
Fillable Fileable
Form
none
Demographic Sheet
Att 5 Resp Data Collect.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 and Demographic Surveys Conducted in Probability Samples of the US Population
FR Citation:
49 FR 37693
Number of Respondents:
92
Number of Respondents for Small Entity:
0
Affected Public:
Private Sector
Private Sector:
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
92
0
92
0
0
0
Annual IC Time Burden (Hours)
26
0
26
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
Letter to Dr. Schwab
Scorecard 10day ltr 041816.docx
04/19/2016
Advance Letter
Att 2 Invite letter.docx
04/19/2016
Consent
Att 4 Informed Consent 040616.docx
04/19/2016
Thank you letter
Att 6 Thank You letter.docx
04/19/2016
Special consent
Att 7 Spec Consent 040616.docx
04/19/2016
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.