Information Collection

Eisenberg Center Customer Satisfaction Survey for the Effective Health Care Program

IC 190004 under ICR 200702-0935-002 · OMB 0935-0128.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0935-0128 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Form #2 Eisenberg Center Customer Satisfaction Survey for the Effective Health Care Program	Form and Instruction
Form #1 Consumer Summary Guides from people with the conditions Attachment B1 -- Oral meds for Type 2 diabetes consumer guide _ feedback survey for people with type 2 diabetes.doc	Form and Instruction
Form #2 Consumer Summary Guides from health care providers - fee Attachment B2 -- Oral meds for Type 2 diabetes consumer guide _ feedback survey for health care providers.doc	Form and Instruction
Form #3 Clinician and Policymaker Summary Guides from health car Attachment B3 -- Oral meds for Type 2 diabetes clinician guide _ feedback survey for health care providers.doc	Form and Instruction
Form #4 Clinician and Policymaker Summary Guides from policymake Attachment B4 -- Oral meds for Type 2 diabetes clinician guide _ feedback survey for policymakers _ administrators.doc	Form and Instruction
Form #5 Osteoporosis Decision Aid - feedback questionnaire Attachment C1 -- Screen shots of the osteoporosis decision aid.doc	Form and Instruction
Form #6 Glossary feedback questionnaire Attachment D -- Glossary feedback questionnaire.doc	Form and Instruction
Form #7 Sample CME Followup Questionnaire Attachment E1 -- Sample CME Followup Questionnaire.doc	Form and Instruction
Supporting Statement Part A EHC combined 7-1-09.doc Supporting Statement Part A EHC combined 7-1-09	IC Document
Supporting Statement Part B EHC combined 5-29-09.doc Supporting Statement Part B EHC combined 5-29-09	IC Document
Attachment C1 -- Screen shots of the osteoporosis decision aid.doc Attachment C1 -- Screen shots of the osteoporosis decision aid	IC Document
TERMS OF CLEARANCE.doc Terms of Clearance	IC Document
PASSBACK 9-18-09.doc AHRQ 9-18-09 memo	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Eisenberg Center Customer Satisfaction Survey for the Effective Health Care Program

Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	Form #2	Consumer Summary Guides from health care providers - feedback questionnaire	Attachment B2 -- Oral meds for Type 2 diabetes consumer guide _ feedback survey for health care providers.doc	Yes	Yes	Fillable Fileable
Form and Instruction	Form #3	Clinician and Policymaker Summary Guides from health care providers - feedback questionnaire	Attachment B3 -- Oral meds for Type 2 diabetes clinician guide _ feedback survey for health care providers.doc	Yes	Yes	Fillable Fileable
Form and Instruction	Form #4	Clinician and Policymaker Summary Guides from policymakers & administrators - feedback questionnaire	Attachment B4 -- Oral meds for Type 2 diabetes clinician guide _ feedback survey for policymakers _ administrators.doc	Yes	Yes	Fillable Fileable
Form and Instruction	Form #5	Osteoporosis Decision Aid - feedback questionnaire	Attachment C1 -- Screen shots of the osteoporosis decision aid.doc	Yes	Yes	Fillable Fileable
Form and Instruction	Form #6	Glossary feedback questionnaire	Attachment D -- Glossary feedback questionnaire.doc	Yes	Yes	Fillable Fileable
Form and Instruction	Form #7	Sample CME Followup Questionnaire	Attachment E1 -- Sample CME Followup Questionnaire.doc	Yes	Yes	Fillable Fileable
Form and Instruction	Form #1	Consumer Summary Guides from people with the conditions - feedback questionnaire	Attachment B1 -- Oral meds for Type 2 diabetes consumer guide _ feedback survey for people with type 2 diabetes.doc	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,320

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	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	1,320	0	0	0	0	0
Annual IC Time Burden (Hours)	110	0	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Supporting Statement Part A EHC combined 7-1-09	Supporting Statement Part A EHC combined 7-1-09.doc	07/02/2009
Supporting Statement Part B EHC combined 5-29-09	Supporting Statement Part B EHC combined 5-29-09.doc	07/02/2009
Attachment C1 -- Screen shots of the osteoporosis decision aid	Attachment C1 -- Screen shots of the osteoporosis decision aid.doc	07/02/2009
Terms of Clearance	TERMS OF CLEARANCE.doc	09/29/2009
AHRQ 9-18-09 memo	PASSBACK 9-18-09.doc	09/29/2009

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.