A Survey of Physicians in Solo and Smaller Primary Care Practices

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

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Document Name Document Type
Form Form #1 A Survey of Physicians in Solo and Smaller Primary Care Practices Form
Form #1 Cognitive testing questionnaire Attachment A - Cognitive testing questionnaire.docx Form
Form #2 Pilot survey questionnaire Attachment B - Pilot survey questionnaire.docx Form
Form #3 Follow-up interview guide Attachment C - Follow up interview guide.docx Form
Attachment E - IH reminder postcard.docx Attachment E - IH reminder postcard IC Document
Attachment D - IH Initial Contact Letter.docx Attachment D - IH Initial Contact Letter IC Document
Attachment F - IH Follow-up Letter.docx Attachment F - IH Follow-up Letter IC Document
SS Part B -- A Survey of Physicians in Solo Smaller PCPs 07 23 12.docx SS Part B -- A Survey of Physicians in Solo Smaller PCPs 07 23 12 IC Document
SS Part A -- A Survey of Physicians in Solo Smaller PCPs 07 23 12.docx SS Part A -- A Survey of Physicians in Solo Smaller PCPs 07 23 12 IC Document

Information Collection (IC) Details

IC Title:	A Survey of Physicians in Solo and Smaller Primary Care Practices	Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	Form #1	Cognitive testing questionnaire	Attachment A - Cognitive testing questionnaire.docx	Yes	Yes	Paper Only
Form	Form #2	Pilot survey questionnaire	Attachment B - Pilot survey questionnaire.docx	Yes	Yes	Paper Only
Form	Form #3	Follow-up interview guide	Attachment C - Follow up interview guide.docx	Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 355	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 %

	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	355	0	0	0	0	0
Annual IC Time Burden (Hours)	90	0	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Attachment E - IH reminder postcard	Attachment E - IH reminder postcard.docx	08/06/2012
Attachment D - IH Initial Contact Letter	Attachment D - IH Initial Contact Letter.docx	08/06/2012
Attachment F - IH Follow-up Letter	Attachment F - IH Follow-up Letter.docx	08/06/2012
SS Part B -- A Survey of Physicians in Solo Smaller PCPs 07 23 12	SS Part B -- A Survey of Physicians in Solo Smaller PCPs 07 23 12.docx	08/06/2012
SS Part A -- A Survey of Physicians in Solo Smaller PCPs 07 23 12	SS Part A -- A Survey of Physicians in Solo Smaller PCPs 07 23 12.docx	08/06/2012

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