Connecting Primary Care Practices with Hard-to-Reach Adolescent Populations

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form Form #11 Semi-structured interviews for the draft manual	Form and Instruction	New	Available
Form Form #10 Administrator-staff semi-structured interviews	Form and Instruction	New	Available
Form Form #9 Clinician semi-structured interviews	Form and Instruction	New	Available
Form Form #8 Adolescent "think-aloud" sessions	Form and Instruction	New	Available
Form Form #7 Adolescent focus groups	Form and Instruction	New	Available
Form Form #6 Post-visit satisfaction survey	Form and Instruction	New	Available
Form Form #5 Adolescent behavior and communication survey	Form and Instruction	New	Available
Form Form #3 Adolescent behavior and communication survey consent-assent form	Form and Instruction	New	Available
Form Form #2 Extraction of medical record data	Form and Instruction	New	Available
Form Form #1 RAAPS questionnaire	Form and Instruction	New	Available
Supporting Statement Part B -- Connecting PCP with Hard to Reach Adolescent Pop 3-8-2011.doc	Supporting Statement B	Uploaded 2011-03-30	Available
Attachment A -- Healthcare Research and Quality Act of 1999.pdf	Supplementary Document	Uploaded 2011-03-30	Available
Attachment N -- Federal Register Notice.pdf	Supplementary Document	Uploaded 2011-03-30	Available
Attachment D -- Adolescent Behavior and Communication Survey Information Letter.doc	Supplementary Document	Uploaded 2011-03-30	Available
Supporting Statement Part A -- Connecting PCP with Hard to Reach Adolescent Pop 9-12-2011.doc	Supporting Statement A	Uploaded 2011-09-12	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
197276	Semi-structured interviews for the draft manual	Form and Instruction	New
197275	Administrator-staff semi-structured interviews	Form and Instruction	New
197274	Clinician semi-structured interviews	Form and Instruction	New
197273	Adolescent "think-aloud" sessions	Form and Instruction	New
197272	Adolescent focus groups	Form and Instruction	New
197271	Post-visit satisfaction survey	Form and Instruction	New
197270	Adolescent behavior and communication survey	Form and Instruction	New
197269	Adolescent behavior and communication survey consent-assent form	Form and Instruction	New
197268	Extraction of medical record data	Form and Instruction	New
197267	RAAPS questionnaire	Form and Instruction	New

ICR Details

OMB Control No: 0935-0184	ICR Reference No: 201104-0935-003
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/AHRQ	Agency Tracking No:
Title: Connecting Primary Care Practices with Hard-to-Reach Adolescent Populations
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: Approved with change	Conclusion Date: 09/27/2011
	Date Received in OIRA: 04/12/2011
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2012	12 Months From Approved
Responses	1,996	0	0
Time Burden (Hours)	479	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The overall goal of this exploratory project is to improve the quality of adolescent health care. The project will address suboptimal adolescent care with respect to health risk behaviors, which can have serious health consequences. In particular, failure to address health risk behaviors among adolescents (e.g., smoking, substance abuse, poor diets, physical inactivity, and high-risk sexual behavior) contributes significantly to increased morbidity and mortality. Adolescents (11-17 years of age) constitute 17% of the population of the U.S., but they are responsible for only 7% of medical office visits. As a result, primary care providers have relatively less opportunity to evaluate and counsel adolescents in their offices than most other patients. Even when adolescents receive routine health care, open communication with their health care providers may be problematic. A national survey found that the majority of adolescent boys and girls in the U.S. report at least 1 of 8 potential health risks, but most (63%) had not spoken to their doctor about any of these (Klein & Wilson, 2002). Improved engagement and communication between adolescents and their primary care providers could increase the likelihood that effective preventive services and health care are provided. It could also improve the efficiency of health care services for adolescents, in terms of appointments kept and adherence to recommended screening or treatment recommendations.

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Authorizing Statute(s): US Code: 42 USC 299 Name of Law: Healthcare Research and Quality Act of 1999
  

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 2390	01/13/2011
30-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 16780	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: 10

table that charts list of burden

IC Title	Form No.	Form Name
RAAPS questionnaire	Form #1	RAAPS Questionnaire
Extraction of medical record data	Form #2	Extraction of medical record data
Adolescent behavior and communication survey consent-assent form	Form #3	Adolescent behavior and communication survey consent-assent form
Adolescent behavior and communication survey	Form #5, Form #4	Adolescent Behavior and Communication Survey 6 Months ,   Adolescent Behavior and Communication Survey Baseline
Post-visit satisfaction survey	Form #6	Post-Visit Survey
Adolescent focus groups	Form #7	Adolescent Focus Group Guide
Adolescent "think-aloud" sessions	Form #8	Adolescent Think Aloud Guide
Clinician semi-structured interviews	Form #9	Clinician Interview Guide
Administrator-staff semi-structured interviews	Form #10	Administrator-Staff Interview Guide
Semi-structured interviews for the draft manual	Form #11	Review of Draft Manual Interview Guide

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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	1,996	0	0	1,996	0	0
Annual Time Burden (Hours)	479	0	0	479	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

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: This submission is for a new information collection request.

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Annual Cost to Federal Government: $436,524

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: 04/12/2011

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