Noa 1-31-2005

NOTICE OF OFFICE OF MANAGEMENT AND BUDGET ACTION
Date 01/31/2005
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
11/15/2004
ACTION REQUESTED: New collection (Request for a new OMB Control Number)
TYPE OF REVIEW REQUESTED: Regular
ICR REFERENCE NUMBER: 200411-0935-001
TITLE: Questionnaire and Data Collection Testing, Evaluation, and Research for the Agency for
Healthcare Research and Quality
LIST OF INFORMATION COLLECTIONS: See next page
OMB ACTION: Approved with change
OMB CONTROL NUMBER: 0935-0124
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
0
10,500
0
10,500
0
0

HOURS
0
5,200

COSTS
0
0

0
5,200
0
0

0
0
0
0

TERMS OF CLEARANCE: Approved consistent with AHRQ memo submitted to OMB 01/26/05.
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.
OMB Authorizing Official:

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

List of ICs
IC Title
Questionnaire and Data
Collection Testing,
Evaluation, and
Research for the
Agency for Healthcare
Research and Quality

Form No.

Form Name

CFR Citation