View Information Collection Request (ICR) Package
Skip to main content
An official website of the United States government
The .gov means it's official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you're on a federal government site.
The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.
Search:
Agenda
Reg Review
ICR
This script is used to control the display of information in this page.
Display additional information by clicking on the following:
All
Brief and OIRA conclusion
Abstract/Justification
Legal Statutes
Rulemaking
FR Notices/Comments
IC List
Burden
Misc.
Common Form Info.
Certification
View Information Collection (IC) List
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:
202009-0935-003
Status:
Historical Active
Previous ICR Reference No:
201708-0935-002
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:
01/19/2021
Retrieve Notice of Action (NOA)
Date Received in OIRA:
10/27/2020
Terms of Clearance:
Inventory as of this Action
Requested
Previously Approved
Expiration Date
01/31/2024
36 Months From Approved
01/31/2021
Responses
13,800
0
13,800
Time Burden (Hours)
8,900
0
8,900
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:
85 FR 35425
06/10/2020
30-day Notice:
Federal Register Citation:
Citation Date:
85 FR 58059
09/17/2020
Did the Agency receive public comments on this ICR?
No
Number of Information Collection (IC) in this ICR:
9
IC Title
Form No.
Form Name
Feasibility Study for a MEPS Monthly Check-In
1I, 1H, 1B, 1C, 1F, 1G, 2B, 2E
Attachment 1-B. Study 1 Recruitment screener
,
Attachment 1-B. Study 1 Recruitment screener
,
Attachment 1-F. Study 1 MCI Protocol 1
,
Attachment 1-G. Study 1 MCI Protocol 2
,
Attachment 1-H. Study 1 Protocol 3 (R2)
,
Attachment 1-I. Study 1 MEPS Abbreviated R2 Interview
,
Attachment 2-B. Study 2 Recruitment telephone script + scheduling MCI interview
,
Attachment 2-E. Study 2 MCI Protocol
Field Test of A Survey of End-of-Life Care
1
Survey of End-of-Life Care
MEPS Alternative Sampling Design Pilot Test
1
Pilot Screener
Patient and Caregiver Survey
1
Patient and Caregiver Survey
Patient and Caregiver Usability Interview
1
Patient and Caregiver Usability Interview
Pilot Test of the Proposed Workplace Safety Supplemental Item Set For the AHRQ Surveys on Patient Safety Culture™ (SOPS®) Nursing Home Survey
Attachment F, 3, 1, 2
Attachment B: Draft Workplace Safety Cognitive Interview Guide
,
Attachment C: Nursing Home Point of Contact (POC) Instructions
,
Attachment A: Draft Workplace Safety Supplemental Item Set
,
Nursing Home Background Information Form
Pilot Test of the Revised Data Collection Method for the Medical Expenditure Panel Survey - Insurance Component
1, 2
Pilot test – Establishment Questionnaire
,
Pilot test – Plan Questionnaire
Provider Focus Group
1
Provider Focus Group
Provider and Patient Interview
1
Provider and Patient Interview
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
13,800
0
0
0
0
Annual Time Burden (Hours)
8,900
8,900
0
0
0
0
Annual Cost Burden (Dollars)
0
0
0
0
0
0
Burden increases because of Program Change due to Agency Discretion:
No
Burden Increase Due to:
Burden decreases because of Program Change due to Agency Discretion:
No
Burden Reduction Due to:
Short Statement:
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?
No
Agency Contact:
Erwin Brown 301 427-1652 erwin.brown@ahrq.hhs.gov
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:
10/27/2020
An official website of the United States government
The .gov means it's official.
The site is secure.
