Information Collection

AHRQ Publicity Center Patient-Centered Outcomes Research Awareness Campaign Health Care Provider Concept Testing

IC 201963 under ICR 201104-0935-002 · OMB 0935-0124.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0935-0124 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Form #1 Screening Questionnaire AHRQ Publicity Center Patient-Centered Outcomes Research Awareness Campaign Health Care Provider Concept Testing	Form and Instruction
Form Form #2 Focus Group Moderator Guide AHRQ Publicity Center Patient-Centered Outcomes Research Awareness Campaign Health Care Provider Concept Testing	Form and Instruction
Form #1 Screening Questionnaire Attachment A - Screening Questionnaire.docx	Form and Instruction
Form #2 Focus Group Moderator Guide Attachment B - Focus Group Moderator Guide.docx	Form and Instruction
Supporting Statement Part A -- AHRQ Publicity Center Patient-Centered Outcomes Research 4 12 12.docx Supporting Statement Part A -- AHRQ Publicity Center Patient-Centered Outcomes Research 4 12 12	IC Document
Attachment C - Focus Group Consent Form.docx Attachment C - Focus Group Consent Form	IC Document
Attachment D - Draft Advertisements.pptx Attachment D - Draft Advertisements	IC Document

IC Title:

AHRQ Publicity Center Patient-Centered Outcomes Research Awareness Campaign Health Care Provider Concept Testing

Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	Form #1	Screening Questionnaire	Attachment A - Screening Questionnaire.docx		Yes	Yes	Paper Only
Form and Instruction	Form #2	Focus Group Moderator Guide	Attachment B - Focus Group Moderator Guide.docx		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 410

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to New Statute	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA	Previously Approved
Annual Number of Responses for this IC	410	0	0	0	0	0
Annual IC Time Burden (Hours)	162	0	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Supporting Statement Part A -- AHRQ Publicity Center Patient-Centered Outcomes Research 4 12 12	Supporting Statement Part A -- AHRQ Publicity Center Patient-Centered Outcomes Research 4 12 12.docx	04/13/2012
Attachment C - Focus Group Consent Form	Attachment C - Focus Group Consent Form.docx	04/13/2012
Attachment D - Draft Advertisements	Attachment D - Draft Advertisements.pptx	04/13/2012

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.