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

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form Form #1 Emergency Preparedness and Response Capabilities Interview Protocol	Form and Instruction	New	Available
Form Form #3 Follow-up interview guide	Form	New	Available
Form Form #2 Pilot survey questionnaire	Form	New	Available
Form Form #1 Cognitive testing questionnaire	Form	New	Available
Form Form #2 Focus Group Moderator Guide	Form and Instruction	New	Available
Form Form #1 Screening Questionnaire	Form and Instruction	New	Available
Form Form #1 Quick Response Survey Questionnaire	Form	New	Available
Form Form #1 CAHPS Cancer Care Questionnaires	Form and Instruction	New	Available
Form Form #2 Cognitive Interview Guide	Form and Instruction	New	Available
Form Form #1 Screener Questionnaire	Form and Instruction	New	Available
Supporting Statement Part B -- Generic Pretesting Clearance 5-10-2011.doc	Supporting Statement B	Uploaded 2011-05-20	Available
Attachment A -- Healthcare Research and Quality Act of 1999.pdf	Supplementary Document	Uploaded 2011-03-31	Available
Attachment C -- Federal Register Notice.pdf	Supplementary Document	Uploaded 2011-03-31	Available
Attachment B -- Examples.doc	Supplementary Document	Uploaded 2011-03-31	Available
Supporting Statement Part A -- Generic Pretesting Clearance 12-23-2010.doc	Supporting Statement A	Uploaded 2011-05-25	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
209426	Pilot Test of an Interview Protocol Designed to Evaluate Emergency Preparedness and Response Capabilities	Form and Instruction	New	Emergency Preparedness and Response Capabilities Interview Protocol
203647	A Survey of Physicians in Solo and Smaller Primary Care Practices	Form	New	Follow-up interview guide
203647	A Survey of Physicians in Solo and Smaller Primary Care Practices	Form	New	Pilot survey questionnaire
203647	A Survey of Physicians in Solo and Smaller Primary Care Practices	Form	New	Cognitive testing questionnaire
201963	AHRQ Publicity Center Patient-Centered Outcomes Research Awareness Campaign Health Care Provider Concept Testing	Form and Instruction	New	Focus Group Moderator Guide
201963	AHRQ Publicity Center Patient-Centered Outcomes Research Awareness Campaign Health Care Provider Concept Testing	Form and Instruction	New	Screening Questionnaire
200807	Pretest of the Medical Expenditure Panel Survey	Form	New	Quick Response Survey Questionnaire
200167	Pretest of Proposed CAHPS for Cancer Care Questions and Methodology	Form and Instruction	New	CAHPS Cancer Care Questionnaires
197779	Cognitive Testing of the MEPS Cancer SAQ	Form and Instruction	New	Cognitive Interview Guide
197779	Cognitive Testing of the MEPS Cancer SAQ	Form and Instruction	New	Screener Questionnaire

ICR Details

OMB Control No: 0935-0124	ICR Reference No: 201104-0935-002
Status: Historical Active	Previous ICR Reference No: 200801-0935-001
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: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 05/27/2011
Retrieve Notice of Action (NOA)	Date Received in OIRA: 04/08/2011
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.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2014	36 Months From Approved	05/31/2011
Responses	4,600	0	11,200
Time Burden (Hours)	2,967	0	4,335
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:
	76 FR 2121	01/12/2011
30-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 16778	03/25/2011
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 6

table that charts list of burden

IC Title	Form No.	Form Name
A Survey of Physicians in Solo and Smaller Primary Care Practices	Form #1, Form #2, Form #3	Cognitive testing questionnaire ,   Pilot survey questionnaire ,   Follow-up interview guide
AHRQ Publicity Center Patient-Centered Outcomes Research Awareness Campaign Health Care Provider Concept Testing	Form #2, Form #1	Screening Questionnaire ,   Focus Group Moderator Guide
Cognitive Testing of the MEPS Cancer SAQ	Form #2, Form #1	Cognitive Interview Guide ,   Screener Questionnaire
Pilot Test of an Interview Protocol Designed to Evaluate Emergency Preparedness and Response Capabilities	Form #1	Emergency Preparedness and Response Capabilities Interview Protocol
Pretest of Proposed CAHPS for Cancer Care Questions and Methodology	Form #1	CAHPS Cancer Care Questionnaires
Pretest of the Medical Expenditure Panel Survey	Form #1	Quick Response Survey Questionnaire

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ICR Summary of Burden

table that charts list 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	4,600	11,200	0	0	-6,600	0
Annual Time Burden (Hours)	2,967	4,335	0	0	-1,368	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]? 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)? No

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: 04/08/2011

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