Attachment D -- NOA 1-3-2005

NOTICE OF OFFICE OF MANAGEMENT AND BUDGET ACTION
Date 01/03/2005
Department of Health and Human Services
Agency for Healthcare Research and Quality
FOR CERTIFYING OFFICIAL:
FOR CLEARANCE OFFICER:
In accordance with the Paperwork Reduction Act, OMB has taken action on your request received
09/30/2004
ACTION REQUESTED: Revision of a currently approved collection
TYPE OF REVIEW REQUESTED: Regular
ICR REFERENCE NUMBER: 200409-0935-002
TITLE: Voluntary Customer Surveys Generic Clearance for the Agency for Healthcare Research
and Quality
LIST OF INFORMATION COLLECTIONS: See next page
OMB ACTION: Approved with change
OMB CONTROL NUMBER: 0935-0106
The agency is required to display the OMB Control Number and inform respondents of its legal
significance in accordance with 5 CFR 1320.5(b).
EXPIRATION DATE: 01/31/2008
BURDEN:
Previous
New
Difference
Change due to New Statute
Change due to Agency Discretion
Change due to Agency Adjustment
Change due to PRA Violation

DISCONTINUE DATE:
RESPONSES
112,800
103,400
0
-9,400
0
0

HOURS
20,667
16,356

COSTS
515,732,000
515,732,000

0
-4,311
0
0

0
0
0
0

TERMS OF CLEARANCE: Approved consistent with AHRQ memo submitted to OMB 12/08/04
detailing Privacy Act Language that will accompany collections under this generic clearance as
appropriate. This generic collection is approved on the following conditions :(1) AHRQ must seek
and receive OMB approval for each individual survey prior to using the survey in the field. (2) AHRQ
will provide a discussion of any proposed incentives and Privacy Act Requirements in each
submission under this generic (3) AHRQ will provide the total approved burden, the requested
burden, and the total burden currently in use under the generic clearance with each submission.
OMB will review requests under this clearance within 10 days of submission and will either approve
requested collections or provide questions and comments.
OMB Authorizing Official:

Donald R. Arbuckle
Deputy Administrator,
Office of Information and Regulatory Affairs

List of ICs
IC Title
Voluntary Customer
Surveys Generic
Clearance for the
Agency for Healthcare
Research and Quality

Form No.

Form Name

CFR Citation