Questionnaire and Data Collection Testing, Evaluation, and Research for the Agency for Healthcare Research and Quality

Forms and Documents

Document Name	Status
Form Form #1 VALIDATION PILOT FOR THE AHRQ PATIENT SAFETY INDICATORS PHASE II Form and Instruction	New
Supporting Statement Part B 1-2-2008.doc Supporting Statement B	2008-01-16
CAHPS Health Literacy Supporting Statement Part B.doc Supplementary Document	2008-01-16
CAHPS Health Literacy Supporting Statement Part A.doc Supplementary Document	2008-01-16
CAHPS Health Literacy Attachment B Questionnaire.doc Supplementary Document	2008-01-16
Cover Letter -- 0935-0124.doc Supplementary Document	2008-01-15
NOA 1-31-2005.pdf Supplementary Document	2008-01-08
CAHPS Health Literacy Attachment C Cover Letter Reminder Post Card Reminder Letter and Telephone Introductory Script.doc Supplementary Document	2008-01-16
ATTACHMENT B -- Examples.doc Supplementary Document	2008-01-08
Attachment A -- AHRQ Legislation.pdf Supplementary Document	2008-01-08
Attachment C -- 30 day notice 12-06-2007.pdf Supplementary Document	2008-01-16
Supporting Statement Part A 11-26-2007.doc Supporting Statement A	2008-01-08

IC Document Collections

IC ID	Document Title	Status
185563	VALIDATION PILOT FOR THE AHRQ PATIENT SAFETY INDICATORS PHASE II Form and Instruction	New

ICR Details

OMB Control No: 0935-0124	ICR Reference No: 200801-0935-001
Status: Historical Active	Previous ICR Reference No: 200606-0935-002
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: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 04/03/2008
	Date Received in OIRA: 01/28/2008
Terms of Clearance: This clearance request is approved as submitted, consistent with AHRQ's statment that it is limited to research on data collection and estimation procedures and reports and does not extend to the collection of data for public release or policy formation. Further, AHRQ will: AHRQ will submit individual requests under this generic clearance to OMB including 1. a running tally of the total number of approved hours and respondents currently in use under the generic clearance; in the event that additional hours are required, AHRQ should submit an 83-C change worksheet to OMB 2. a justification section describing the proposed collection and any planned analysis in detail, specifically addressing the relevance of the collection to the overall structure of the generic clearance. OMB will attempt to provide comments within ten days of official receipt of individual clearance requests under this generic. AHRQ must receive explicit OMB approval prior to the fielding of any proposed collections under this clearance. Key in OMB's review of the individual items will be the appropriateness of the instrument and methodology for its intended purpose and ensuring that the item is consistent with the terms of this generic clearance.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2011	36 Months From Approved	04/30/2008
Responses	11,200	0	10,500
Time Burden (Hours)	4,335	0	5,200
Cost Burden (Dollars)	0	0	0

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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.

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Authorizing Statute(s): None

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	72 FR 45817	08/15/2007
30-day Notice:	Federal Register Citation:	Citation Date:
	72 FR 68885	12/06/2007
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
VALIDATION PILOT FOR THE AHRQ PATIENT SAFETY INDICATORS PHASE II	Form #1, Form #3, Form #2, Form #4, Form #5, Form #6, Form #7	Interest form ,   Foreign body left during procedure abstraction tool ,   Participant survey ,   Postoperative hemorrhage or hematoma abstraction tool ,   Postoperative physiologic & metabolic derangement abstraction tool ,   Postoperative respiratory failure abstraction tool ,   Postoperative wound dehiscence abstraction tool

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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	11,200	10,500	0	0	700	0
Annual Time Burden (Hours)	4,335	5,200	0	0	-865	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:

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Annual Cost to Federal Government: $640,000

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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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: 01/28/2008

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