Evaluation of Medicare Personal Health Records Choice Pilot

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
0990-PHRChoicepilot- Part B (2).doc	Supporting Statement B	Uploaded 2010-09-23	Repair queued
0990-Medicare PHRAppx D2 DRAFT patient FOLLOWUP Letter.doc	Supplementary Document	Uploaded 2010-09-23	Repair queued
0990-PHRC-Appx C surveys consulted.doc	Supplementary Document	Uploaded 2010-09-23	Repair queued
0990-Medicare PHR Appx D1 DRAFT patient letter.doc	Supplementary Document	Uploaded 2010-09-23	Repair queued
0990-Medicare PHR Part A april 22 10 (2).doc	Supporting Statement A	Uploaded 2010-09-23	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
192996	Medicare beneficiaries	Other-phone script	Modified

ICR Details

OMB Control No:	ICR Reference No: 201009-0990-003
Status: Historical Inactive	Previous ICR Reference No: 201005-0990-001
Agency/Subagency: HHS/HHSDM	Agency Tracking No:
Title: Evaluation of Medicare Personal Health Records Choice Pilot
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Withdrawn	Conclusion Date: 11/02/2010
	Date Received in OIRA: 09/24/2010
Terms of Clearance: Withdrawn at request of HHS

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date		36 Months From Approved
Responses	0	0	0
Time Burden (Hours)	0	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: HHS' Office of the Assistant Secretary for Planning and Evaluation (ASPE) will conduct an evaluation of this pilot program. The evaluation will draw from several data sources, including a PHR enrollee user satisfaction survey to assess barriers, facilitators, and satisfaction with the PHRs. A self-administered paper-and-pencil instrument will be the primary data collection mode for the PHRC user satisfaction survey, with telephone followup for mail nonrespondents.

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Authorizing Statute(s): PL: Pub.L. 111 - 5 1 Name of Law: American Recovery and Reinvestment Act
  

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:
	75 FR 7268	02/18/2010
30-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 27346	05/14/2010
Did the Agency receive public comments on this ICR? No

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

table that charts list of burden

IC Title	Form No.	Form Name
Medicare beneficiaries

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Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: New collection

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Annual Cost to Federal Government: $579,475

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]? 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)? Yes

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: 09/24/2010

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