View Information Collection Request (ICR) Package
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View Supporting Statement and Other Documents
Please note that the OMB number and expiration date may not have been determined when this Information Collection Request and associated Information Collection forms were submitted to OMB. The approved OMB number and expiration date may be found by clicking on the Notice of Action link below.
View Generic ICR - OIRA Conclusion
OMB Control No:
0935-0124
ICR Reference No:
201708-0935-002
Status:
Historical Active
Previous ICR Reference No:
201409-0935-002
Agency/Subagency:
HHS/AHRQ
Agency Tracking No:
Title:
Questionnaire and Data Collection Testing, Evaluation, and Research for the Agency for Healthcare Research and Quality
Type of Information Collection:
Extension without change of a currently approved collection
Common Form ICR:
No
Type of Review Request:
Regular
OIRA Conclusion Action:
Approved without change
Conclusion Date:
11/03/2017
Retrieve Notice of Action (NOA)
Date Received in OIRA:
08/07/2017
Terms of Clearance:
Inventory as of this Action
Requested
Previously Approved
Expiration Date
11/30/2020
36 Months From Approved
11/30/2017
Responses
13,800
0
4,600
Time Burden (Hours)
8,900
0
2,967
Cost Burden (Dollars)
0
0
0
Abstract:
Work conducted under this clearance is intended to improve AHRQ's current data collections by developing new surveys and revising surveys and to test survey instruments more quickly.
Authorizing Statute(s):
None
Citations for New Statutory Requirements:
None
Associated Rulemaking Information
RIN:
Stage of Rulemaking:
Federal Register Citation:
Date:
Not associated with rulemaking
Federal Register Notices & Comments
60-day Notice:
Federal Register Citation:
Citation Date:
82 FR 19727
04/28/2017
30-day Notice:
Federal Register Citation:
Citation Date:
82 FR 35205
07/28/2017
Did the Agency receive public comments on this ICR?
No
Number of Information Collection (IC) in this ICR:
12
IC Title
Form No.
Form Name
Advancing the Collection and Use of Patient –Reported Outcomes through Health Information Technology
2, 1, 3
Attachment A. PROMIS Item Bank V2.0
,
Process Usage Worksheet (Patients)
,
Attachment D: Process Usage Worksheet (Providers)
Cognitive Testing of the Medical Expenditure Panel Survey (MEPS) Health Insurance Verification Module
C1, B1
Attachment B – Screening Questionnaire
,
Attachment C1 - Cognitive Interview Guide and Questionnaire
Environmental Scan for Guide to Improving Patient Safety in Primary Care Settings by Engaging Patients and Families
6, 4, 2, 8, 7, 1, 3, 5
Attachment B: Key Informant Interview Guide- In-person
,
Attachment D: Interview Guide for Case Study Development- In-person
,
Attachment F: Interview Guide for Patients/Family Members/Caregivers- In-person
,
Attachment H: Interview Guide for Primary Care Practice Staff and Physicians- In-person
,
Attachment A: Key Informant Interview Guide- Telephone
,
Attachment C: Interview Guide for Case Study Development- Telephone
,
Attachment E: Interview Guide for Patients/Family Members/Caregivers- Telephone
,
Attachment G: Interview Guide for Primary Care Practice Staff and Physicians- Telephone
Field Test of Low Literacy Version of CAHPS Clinician and Group Survey
1, 2
CG-CAHPS EZ /CG-CAHPS - English
,
CG-CAHPS EZ /CG-CAHPS - Spanish
Field Test of SPPC-II Toolkit and Training Modules during Pilot Phase of SPPC-II Demonstration Project
2, 1, 2, 1
Attachment B – Field Test Interview Guides
,
Attachment E – SPPC-II Field Test - Short Questionnaire
,
Attachment B- Field Test Interview Guides Final
,
Attachment E SPPC II Short Questionnaire Final
Identifying, Assessing, and Balancing Competing Risks of Multiple Hospital-Acquired Conditions (HACs)
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)
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)
3
Attachment C – HAC Risk Dashboard Tool Key Informant Interview Guide
Implementation of an Electronic Care Plan for People with Multiple Chronic Conditions
1, 2, 3
Attachment A - Healthcare Staff Interview Guide (for providers & non-providers)
,
Attachment B - Health Information Technology Professional Interview Guide
,
Attachment C - Patient Interview Guide
Pilot Test of the Proposed Diagnostic Safety Supplemental Item Set for the Medical Office Survey on Patient Safety Culture
3, 2, 1, 4, 5
Attachment B: Draft Diagnostic Safety Cognitive Interview Guide
,
Medical office information survey
,
Pilot test
,
Attachment A - Draft Diagnostic Safety Supplemental Item Set 7-3-19.docx
,
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
2, 3, 1
Draft Workforce Safety Cognitive Interview Guide
,
Attachment C: Hospital Point of Contact (POC) Instructions
,
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
2, 1
Attachment B Child HCAHPS Survey 2019-03-11.docx
,
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
1, 2, 3
Attachment G – Interview Guide
,
Initial Screening
,
In Depth Screening
Questionnaire and Data Collection Testing, Evaluation, and Research for the Agency for Healthcare Research and Quality – Marketplaces and Exchanges
1, 2, 3
Attachment G – Interview Protocol
,
Initial Screening
,
In Depth Screening
Testing for Potential Enhancements to the Medical Expenditure Panel Survey: Study on Employer-sponsored Insurance Plans
3, 4, 1, 2
Attachment A – Initial Screening Questionnaire
,
Attachment B – In-depth Screening Questionnaire
,
Attachment D – Participant Consent Form
,
Attachment G – Focus Group Protocol
Testing for Potential Enhancements to the Medical Expenditure Panel Survey: Study on Insurance Plans offered by Local Governments
3, 1, 2
Attachment G – Focus Group Protocol
,
Screening
,
In Depth Screening
Testing for Potential Enhancements to the Medical Expenditure Panel Survey: Study on Insurance Plans offered by State Governments
3, 1, 2
Attachment G – Interview Protocol
,
Initial Screening
,
In Depth Screening
ICR Summary of Burden
Total Approved
Previously Approved
Change Due to New Statute
Change Due to Agency Discretion
Change Due to Adjustment in Estimate
Change Due to Potential Violation of the PRA
Annual Number of Responses
13,800
4,600
0
9,200
0
0
Annual Time Burden (Hours)
8,900
2,967
0
5,933
0
0
Annual Cost Burden (Dollars)
0
0
0
0
0
0
Burden increases because of Program Change due to Agency Discretion:
Yes
Burden Increase Due to:
Miscellaneous Actions
Burden decreases because of Program Change due to Agency Discretion:
No
Burden Reduction Due to:
Short Statement:
These are the same number requested for this Generic Clearance three years ago.
Annual Cost to Federal Government:
$705,392
Does this IC contain surveys, censuses, or employ statistical methods?
Yes
Part B of Supporting Statement
Does this ICR request any personally identifiable information (see
OMB Circular No. A-130
for an explanation of this term)? Please consult with your agency's privacy program when making this determination.
Yes
Does this ICR include a form that requires a Privacy Act Statement (see
5 U.S.C. §552a(e)(3)
)? Please consult with your agency's privacy program when making this determination.
No
Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]?
No
Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]?
No
Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)?
No
Is this ICR related to the Pandemic Response?
Uncollected
Agency Contact:
Doris Lefkowitz 3014271477
Common Form ICR:
No
On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
(a) It is necessary for the proper performance of agency functions;
(b) It avoids unnecessary duplication;
(c) It reduces burden on small entities;
(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;
(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;
(f) It indicates the retention periods for recordkeeping requirements;
(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:
(i) Why the information is being collected;
(ii) Use of information;
(iii) Burden estimate;
(iv) Nature of response (voluntary, required for a benefit, or mandatory);
(v) Nature and extent of confidentiality; and
(vi) Need to display currently valid OMB control number;
(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.
(i) It uses effective and efficient statistical survey methodology (if applicable); and
(j) It makes appropriate use of information technology.
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
Certification Date:
08/07/2017
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