Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 1 National Quality Strategy Stakeholder Survey of Awareness,	Form and Instruction	New	Repair queued
Form 1 Attachment A – Approach Document—Future of MONAHRQ® Survey 2014	Form and Instruction	New	Available
Form 1 AHRQ Patient Safety Network (PSNet)/WebM&M User Satisfaction Survey	Form and Instruction	New	Available
Form 1 Agency for Health Research and Quality (AHRQ) Articles of Interest (AI) Survey	Form and Instruction	New	Available
Form 1 AHRQ WebM&M Customer Satisfaction Survey	Form and Instruction	New	Available
Form 1 Customer Satisfaction Survey of AHRQ PSNet Users	Form and Instruction	New	Available
Form Form #6 Focus Group Moderator Guide - Group2	Form	New	Available
Form Form #5 Focus Group Moderator Guide - Group1	Form	New	Available
Form Form #4 Pre-Focus Group Questionnaire - Group2	Form	New	Repair queued
Form Form #2 Screening Questionnaire	Form	New	Available
Form Form #1 Web-based Survey	Form	New	Available
Form Form #3 Pre-Focus Group Questionnaire - Group1	Form	New	Repair queued
Form Form #2 Attachment C - Health Care Professional Questionnaire	Form and Instruction	New	Available
Form Form #1 Attachment A -- Patient Questionnaire - Spanish Version	Form and Instruction	New	Repair queued
Form Form #2 Adoption and Use of AHRQ QI Questionnaire	Form	New	Available
Form Form #1 AHRQ QI Software and Documentation Questionnaire	Form	New	Available
Form Form #1 Guide to Clinical Preventive Services Feedback Questionnaire	Form	New	Available
Form Form #2 HCUP Partners Software Redesign Questionnaire	Form and Instruction	New	Repair queued
Form Form #1 MONAHRQ Host User Group Questionnaire	Form and Instruction	New	Repair queued
Form Form #3 Monthly Check-in Phone Follow-up	Form and Instruction	New	Repair queued
Form Form #2 Monthly E-mail Check-in Text	Form and Instruction	New	Available
Form Form #4 In-depth Interview Guide	Form and Instruction	New	Available
Form Form #1 Screening Questionnaire	Form and Instruction	New	Available
Form Form #1 Research Activities Newsletter Questionnaire	Form	New	Repair queued
Form Form #2 Focus Group Moderator Guide	Form and Instruction	New	Available
Form Form #1 Screening Questionnaire	Form and Instruction	New	Repair queued
Form Form #1 Focus Group Moderator Guide	Form and Instruction	New	Available
Form Form #2 Screening Instrument for Focus Groups	Form and Instruction	New	Available
Generic Clearance Submission Template.doc	Supplementary Document	Uploaded 2011-06-28	Available
Supporting Statement Part B -- Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery - 4-17-2011.docx	Supporting Statement B	Uploaded 2011-04-26	Available
Attachment A -- Healthcare Research and Quality Act of 1999.pdf	Supplementary Document	Uploaded 2011-04-26	Available
30 Day FRN 4-18-2011.pdf	Supplementary Document	Uploaded 2011-04-26	Available
Supporting Statement Part A -- Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery - 4-17-2011.docx	Supporting Statement A	Uploaded 2011-04-26	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
212741	Stakeholder Information Needs and Satisfaction with National Quality Strategy Outreach Activities	Form and Instruction	New	National Quality Strategy Stakeholder Survey of Awareness,
212537	Future of MONAHRQ® Survey 2014: Current and Potential Host Users	Form and Instruction	New	Attachment A – Approach Document—Future of MONAHRQ® Survey 2014
211832	Voluntary Customer Satisfaction Survey of AHRQ PSNet and AHRQ WebM&M Users	Form and Instruction	New	AHRQ Patient Safety Network (PSNet)/WebM&M User Satisfaction Survey
211678	AHRQ Articles of Interest (AI) Survey	Form and Instruction	New	Agency for Health Research and Quality (AHRQ) Articles of Interest (AI) Survey
211461	Voluntary Customer Satisfaction Survey of AHRQ WebM&M Users	Form and Instruction	New	AHRQ WebM&M Customer Satisfaction Survey
211457	Voluntary Customer Satisfaction Survey of AHRQ PSNet Users	Form and Instruction	New	Customer Satisfaction Survey of AHRQ PSNet Users
207033	Customer Satisfaction with AHRQ's Patient-Centered Outcomes Research (PCOR) Educational Materials	Form	New	Focus Group Moderator Guide - Group2
207033	Customer Satisfaction with AHRQ's Patient-Centered Outcomes Research (PCOR) Educational Materials	Form	New	Focus Group Moderator Guide - Group1
207033	Customer Satisfaction with AHRQ's Patient-Centered Outcomes Research (PCOR) Educational Materials	Form	New	Pre-Focus Group Questionnaire - Group2
207033	Customer Satisfaction with AHRQ's Patient-Centered Outcomes Research (PCOR) Educational Materials	Form	New	Screening Questionnaire
207033	Customer Satisfaction with AHRQ's Patient-Centered Outcomes Research (PCOR) Educational Materials	Form	New	Web-based Survey
207033	Customer Satisfaction with AHRQ's Patient-Centered Outcomes Research (PCOR) Educational Materials	Form	New	Pre-Focus Group Questionnaire - Group1
205936	Customer Satisfaction with the AHRQ Videonovela Aprende a vivir.	Form and Instruction	New	Attachment C - Health Care Professional Questionnaire
205936	Customer Satisfaction with the AHRQ Videonovela Aprende a vivir.	Form and Instruction	New	Attachment A -- Patient Questionnaire - Spanish Version
203598	Customer Satisfaction with the AHRQ Quality Indicators (QI) and QI Software, Documentation and User Support	Form	New	Adoption and Use of AHRQ QI Questionnaire
203598	Customer Satisfaction with the AHRQ Quality Indicators (QI) and QI Software, Documentation and User Support	Form	New	AHRQ QI Software and Documentation Questionnaire
203561	Customer Satisfaction with the 2012 Guide to Clinical Preventive Services	Form	New	Guide to Clinical Preventive Services Feedback Questionnaire
203456	Customer Satisfaction with AHRQ's Quality Measurement Initiatives	Form and Instruction	New	HCUP Partners Software Redesign Questionnaire
203456	Customer Satisfaction with AHRQ's Quality Measurement Initiatives	Form and Instruction	New	MONAHRQ Host User Group Questionnaire
200809	Customer Satisfaction with HIE Evaluation Toolkit	Form and Instruction	New	Monthly Check-in Phone Follow-up
200809	Customer Satisfaction with HIE Evaluation Toolkit	Form and Instruction	New	Monthly E-mail Check-in Text
200809	Customer Satisfaction with HIE Evaluation Toolkit	Form and Instruction	New	In-depth Interview Guide
200809	Customer Satisfaction with HIE Evaluation Toolkit	Form and Instruction	New	Screening Questionnaire
200058	Customer Satisfaction with AHRQ's Research Activities Newsletter	Form	New	Research Activities Newsletter Questionnaire
199654	AHRQ Publicity Center Patient-Centered Outcomes Research Awareness Campaign Concept Testing	Form and Instruction	New	Focus Group Moderator Guide
199654	AHRQ Publicity Center Patient-Centered Outcomes Research Awareness Campaign Concept Testing	Form and Instruction	New	Screening Questionnaire
199213	Customer Satisfaction with AHRQ's Health IT Literacy Guide	Form and Instruction	New	Focus Group Moderator Guide
199213	Customer Satisfaction with AHRQ's Health IT Literacy Guide	Form and Instruction	New	Screening Instrument for Focus Groups

ICR Details

OMB Control No: 0935-0179	ICR Reference No: 201104-0935-006
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/AHRQ	Agency Tracking No:
Title: Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery
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 without change	Conclusion Date: 07/24/2011
Retrieve Notice of Action (NOA)	Date Received in OIRA: 04/28/2011
Terms of Clearance: OMB approves this collection for a period of three years. To request approval of information collections under this generic approval, the agency must do the following: 1) Unless an agency is using multiple modes of collection (e.g., paper forms and electronic submissions), provide a Generic Clearance Submission Template for each Instrument; 2) If the agency is using multiple modes of collection (e.g., paper forms and electronic submissions), the same Generic Clearance Submission Template may be used for both instruments; 3) each Generic Clearance Submission Template must be uploaded as a Supplementary document using a naming convention that allows the public to identify the associated instrument; 4) submit no more than five Generic Submission Templates with each request.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2014	36 Months From Approved
Responses	10,900	0	0
Time Burden (Hours)	3,383	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: This collection of information is necessary to enable the Agency to garner customer and stakeholder feedback in an efficient, timely manner, in accordance with our commitment to improving service delivery. The information collected from our customers and stakeholders will help ensure that users have an effective, efficient, and satisfying experience with the Agency's programs.

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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:
	75 FR 80542	12/22/2010
30-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 21746	04/18/2011
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 15

table that charts list of burden

IC Title	Form No.	Form Name
AHRQ Articles of Interest (AI) Survey	1	Agency for Health Research and Quality (AHRQ) Articles of Interest (AI) Survey
AHRQ Publicity Center Patient-Centered Outcomes Research Awareness Campaign Concept Testing	Form #1, Form #2	Screening Questionnaire ,   Focus Group Moderator Guide
Customer Satisfaction with AHRQ's Health IT Literacy Guide	Form #2, Form #1	Screening Instrument for Focus Groups ,   Focus Group Moderator Guide
Customer Satisfaction with AHRQ's Patient-Centered Outcomes Research (PCOR) Educational Materials	Form #3, Form #1, Form #2, Form #4, Form #5, Form #6	Pre-Focus Group Questionnaire - Group1 ,   Web-based Survey ,   Screening Questionnaire ,   Pre-Focus Group Questionnaire - Group2 ,   Focus Group Moderator Guide - Group1 ,   Focus Group Moderator Guide - Group2
Customer Satisfaction with AHRQ's Quality Measurement Initiatives	Form #1, Form #2	MONAHRQ Host User Group Questionnaire ,   HCUP Partners Software Redesign Questionnaire
Customer Satisfaction with AHRQ's Research Activities Newsletter	Form #1	Research Activities Newsletter Questionnaire
Customer Satisfaction with HIE Evaluation Toolkit	Form #1, Form #4, Form #2, Form #3	Screening Questionnaire ,   In-depth Interview Guide ,   Monthly E-mail Check-in Text ,   Monthly Check-in Phone Follow-up
Customer Satisfaction with the 2012 Guide to Clinical Preventive Services	Form #1	Guide to Clinical Preventive Services Feedback Questionnaire
Customer Satisfaction with the AHRQ Quality Indicators (QI) and QI Software, Documentation and User Support	Form #1, Form #2	AHRQ QI Software and Documentation Questionnaire ,   Adoption and Use of AHRQ QI Questionnaire
Customer Satisfaction with the AHRQ Videonovela Aprende a vivir.	Form #1, Form #2	Attachment A -- Patient Questionnaire - Spanish Version ,   Attachment C - Health Care Professional Questionnaire
Future of MONAHRQ® Survey 2014: Current and Potential Host Users	1	Attachment A – Approach Document—Future of MONAHRQ® Survey 2014
Stakeholder Information Needs and Satisfaction with National Quality Strategy Outreach Activities	1	National Quality Strategy Stakeholder Survey of Awareness,
Voluntary Customer Satisfaction Survey of AHRQ PSNet Users	1	Customer Satisfaction Survey of AHRQ PSNet Users
Voluntary Customer Satisfaction Survey of AHRQ PSNet and AHRQ WebM&M Users	1	AHRQ Patient Safety Network (PSNet)/WebM&M User Satisfaction Survey
Voluntary Customer Satisfaction Survey of AHRQ WebM&M Users	1	AHRQ WebM&M Customer Satisfaction Survey

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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	10,900	0	0	10,900	0	0
Annual Time Burden (Hours)	3,383	0	0	3,383	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 Information Collection Request is for a new generic clearance to allow AHRQ to improve its service delivery.

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Annual Cost to Federal Government: $720,000

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: 04/28/2011

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