Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Feasibility Study for a MEPS Monthly Check-In Unchanged 195 90 0 Form and Instruction 1B Attachment 1-B. Study 1 Recruitment screener
Form and Instruction 1C Attachment 1-B. Study 1 Recruitment screener
Form and Instruction 1F Attachment 1-F. Study 1 MCI Protocol 1
Form and Instruction 1G Attachment 1-G. Study 1 MCI Protocol 2
Form and Instruction 1H Attachment 1-H. Study 1 Protocol 3 (R2)
Form and Instruction 1I Attachment 1-I. Study 1 MEPS Abbreviated R2 Interview
Form and Instruction 2B Attachment 2-B. Study 2 Recruitment telephone script + scheduling MCI interview
Form and Instruction 2E Attachment 2-E. Study 2 MCI Protocol
Instruction
Instruction
Field Test of A Survey of End-of-Life Care Unchanged 510 97 0 Form and Instruction 1 Survey of End-of-Life Care
MEPS Alternative Sampling Design Pilot Test Unchanged 3393 567 0 Form and Instruction 1 Pilot Screener
Patient and Caregiver Survey Unchanged 90 90 0 Form and Instruction 1 Patient and Caregiver Survey
Patient and Caregiver Usability Interview Unchanged 10 10 0 Form and Instruction 1 Patient and Caregiver Usability Interview
Pilot Test of Proposed Revisions to the Nursing Home Survey on Patient Safety Culture (NH SOPS) to Version 2.0, with the Workplace Safety Supplemental Item Set for Nursing Homes New 3012 1248 0 Form and Instruction 1 SOPS Nursing Home Survey with Workplace Safety Supplemental Item Set
Pilot Test of the Proposed Workplace Safety Supplemental Item Set For the AHRQ Surveys on Patient Safety Culture™ (SOPS®) Nursing Home Survey Unchanged 4309 1432 0 Form and Instruction 1 Attachment B: Draft Workplace Safety Cognitive Interview Guide
Form and Instruction 2 Attachment C: Nursing Home Point of Contact (POC) Instructions
Form and Instruction 3 Attachment A: Draft Workplace Safety Supplemental Item Set
Form and Instruction Attachment F Nursing Home Background Information Form
Pilot Test of the Revised Data Collection Method for the Medical Expenditure Panel Survey - Insurance Component Unchanged 3000 1180 0 Form and Instruction 1 Pilot test – Establishment Questionnaire
Form and Instruction 2 Pilot test – Plan Questionnaire
Pretest of the Proposed Revisions to the Medical Office Survey on Patient Safety Culture (MO SOPS) to Version 2.0, with New Workplace Safety Supplemental Items for Medical Offices New 1065 463 0 Form and Instruction 3 Medical Office Point of Contact (POC) Instructions
Form and Instruction 5 Medical Office Background Information Form
Form and Instruction 6 Pretest of SOPS Medical Office Survey 2.0 and Workplace Safety Supplemental Items - REVISED
Form and Instruction 4 Attachment B - Medical Office Data Use Agreement (DUA) - REVISED
Form and Instruction 1, 2 MO Survey Version 2.0 and Workplace Safety Supplemental Items Cognitive Interview Guide - REVISED
Provider Focus Group Unchanged 20 30 0 Form and Instruction 1 Provider Focus Group
Provider and Patient Interview Unchanged 13 13 0 Form and Instruction 1 Provider and Patient Interview
Total Burden Actually Used for Information Collections Under Currently Approved ICR: 15617 5220 0  
Total Burden Currently Requested for Information Collections Under Currently Approved ICR: 0 0 0  
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