Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Advancing the Collection and Use of Patient –Reported Outcomes through Health Information Technology New 899 120 0 Form and Instruction 1 Attachment A. PROMIS Item Bank V2.0
Form and Instruction 2 Process Usage Worksheet (Patients)
Form and Instruction 3 Attachment D: Process Usage Worksheet (Providers)
Cognitive Testing of the Medical Expenditure Panel Survey (MEPS) Health Insurance Verification Module Removed 0 0 0 Form and Instruction B1 Attachment B – Screening Questionnaire
Form and Instruction C1 Attachment C1 - Cognitive Interview Guide and Questionnaire
Environmental Scan for Guide to Improving Patient Safety in Primary Care Settings by Engaging Patients and Families Removed 0 0 0 Form and Instruction 2 Attachment B: Key Informant Interview Guide- In-person
Form and Instruction 4 Attachment D: Interview Guide for Case Study Development- In-person
Form and Instruction 6 Attachment F: Interview Guide for Patients/Family Members/Caregivers- In-person
Form and Instruction 8 Attachment H: Interview Guide for Primary Care Practice Staff and Physicians- In-person
Form and Instruction 1 Attachment A: Key Informant Interview Guide- Telephone
Form and Instruction 3 Attachment C: Interview Guide for Case Study Development- Telephone
Form and Instruction 5 Attachment E: Interview Guide for Patients/Family Members/Caregivers- Telephone
Form and Instruction 7 Attachment G: Interview Guide for Primary Care Practice Staff and Physicians- Telephone
Field Test of Low Literacy Version of CAHPS Clinician and Group Survey New 800 92 0 Form and Instruction 1 CG-CAHPS EZ /CG-CAHPS - English
Form and Instruction 2 CG-CAHPS EZ /CG-CAHPS - Spanish
Field Test of SPPC-II Toolkit and Training Modules during Pilot Phase of SPPC-II Demonstration Project New 32 17 0 Form and Instruction 1 Attachment B – Field Test Interview Guides
Form and Instruction 2 Attachment E – SPPC-II Field Test - Short Questionnaire
Form and Instruction 1 Attachment B- Field Test Interview Guides Final
Form and Instruction 2 Attachment E SPPC II Short Questionnaire Final
Identifying, Assessing, and Balancing Competing Risks of Multiple Hospital-Acquired Conditions (HACs) Removed 0 0 0 Form and Instruction 2 Attachment B – HAC Risk Dashboard Tool Low-Fidelity Prototype Evaluation Focus Group Guide
Identifying, Assessing, and Balancing Competing Risks of Multiple Hospital-Acquired Conditions (HACs) Removed 0 0 0 Form and Instruction 1 Attachment A – HAC Risk Dashboard Tool Information Needs Identification Focus Group Guide
Identifying, Assessing, and Balancing Competing Risks of Multiple Hospital-Acquired Conditions (HACs) Removed 0 0 0 Form and Instruction 3 Attachment C – HAC Risk Dashboard Tool Key Informant Interview Guide
Implementation of an Electronic Care Plan for People with Multiple Chronic Conditions New 34 34 0 Form and Instruction 1 Attachment A - Healthcare Staff Interview Guide (for providers & non-providers)
Form and Instruction 2 Attachment B - Health Information Technology Professional Interview Guide
Form and Instruction 3 Attachment C - Patient Interview Guide
Pilot Test of the Proposed Diagnostic Safety Supplemental Item Set for the Medical Office Survey on Patient Safety Culture New 1545 538 0 Form and Instruction 1 Attachment B: Draft Diagnostic Safety Cognitive Interview Guide
Form and Instruction 2 Medical office information survey
Form and Instruction 3 Pilot test
Form and Instruction 4 Attachment A - Draft Diagnostic Safety Supplemental Item Set 7-3-19.docx
Form and Instruction 5 Attachment B - Diagnostic Safety Cog Interview Guide 7-3-19.docx
Pilot Test of the Proposed Workforce Safety Supplemental Item Set For the Surveys on Patient Safety Culture New 5782 1935 0 Form and Instruction 1 Draft Workforce Safety Cognitive Interview Guide
Form and Instruction 2 Attachment C: Hospital Point of Contact (POC) Instructions
Form and Instruction 3 Attachment A: Draft Workforce Safety Supplemental Item
Pilot Test of the Protocol for Eliciting Patient Narratives from Parents for the Child Hospital Consumer Assessment of Healthcare New 100 75 0 Form and Instruction 1 Attachment B Child HCAHPS Survey 2019-03-11.docx
Form and Instruction 2 Attachment D Intensive interview protocol 2019-03-11.docx
Questionnaire and Data Collection Testing, Evaluation, and Research for the Agency for Healthcare Research and Quality - Insurance Plans Purchased Individually New 245 28 0 Form and Instruction 3 Attachment G – Interview Guide
Form and Instruction 1 Initial Screening
Form and Instruction 2 In Depth Screening
Questionnaire and Data Collection Testing, Evaluation, and Research for the Agency for Healthcare Research and Quality – Marketplaces and Exchanges New 245 28 0 Form and Instruction 3 Attachment G – Interview Protocol
Form and Instruction 1 Initial Screening
Form and Instruction 2 In Depth Screening
Testing for Potential Enhancements to the Medical Expenditure Panel Survey: Study on Employer-sponsored Insurance Plans New 310 45 0 Form and Instruction 1 Attachment A – Initial Screening Questionnaire
Form and Instruction 2 Attachment B – In-depth Screening Questionnaire
Form and Instruction 3 Attachment D – Participant Consent Form
Form and Instruction 4 Attachment G – Focus Group Protocol
Testing for Potential Enhancements to the Medical Expenditure Panel Survey: Study on Insurance Plans offered by Local Governments New 240 23 0 Form and Instruction 3 Attachment G – Focus Group Protocol
Form and Instruction 1 Screening
Form and Instruction 2 In Depth Screening
Testing for Potential Enhancements to the Medical Expenditure Panel Survey: Study on Insurance Plans offered by State Governments New 240 23 0 Form and Instruction 3 Attachment G – Interview Protocol
Form and Instruction 1 Initial Screening
Form and Instruction 2 In Depth Screening
Total Burden Actually Used for Information Collections Under Currently Approved ICR: 10472 2958 0  
Total Burden Currently Requested for Information Collections Under Currently Approved ICR: 0 0 0  
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