Information Collection

Customer Satisfaction with HIE Evaluation Toolkit

IC 200809 under ICR 201104-0935-006 · OMB 0935-0179.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0935-0179 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Form #1 Customer Satisfaction with HIE Evaluation Toolkit	Form and Instruction
Form #1 Screening Questionnaire Attachment E - Screening Questionnaire.docx	Form and Instruction
Form #4 In-depth Interview Guide Attachment C - In-depth Interview Guide.docx	Form and Instruction
Form #2 Monthly E-mail Check-in Text Attachment A - Monthly Email Check-in Text.docx	Form and Instruction
Form #3 Monthly Check-in Phone Follow-up Attachment B - Monthly Check-in Phone Follow-up.docx	Form and Instruction
Attachment D - Recruitment Email.docx Attachment D - Recruitment Email	IC Document
Attachment F - Final Mail to Non-Responders to Two Monthly Follow-ups.docx Attachment F - Final Mail to Non-Responders to Two Monthly Follow-ups	IC Document
OMB Submission Form - Customer Satisfaction with AHRQ's HIE Evaluation Toolkit.docx OMB Submission Form - Customer Satisfaction with AHRQ's HIE Evaluation Toolkit	IC Document

IC Title:

Customer Satisfaction with HIE Evaluation Toolkit

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	Form #1	Screening Questionnaire	Attachment E - Screening Questionnaire.docx	Yes	Yes	Fillable Fileable
Form and Instruction	Form #4	In-depth Interview Guide	Attachment C - In-depth Interview Guide.docx	Yes	Yes	Fillable Fileable
Form and Instruction	Form #2	Monthly E-mail Check-in Text	Attachment A - Monthly Email Check-in Text.docx	Yes	Yes	Fillable Fileable
Form and Instruction	Form #3	Monthly Check-in Phone Follow-up	Attachment B - Monthly Check-in Phone Follow-up.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 60

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	120	0	0	0	0	0
Annual IC Time Burden (Hours)	34	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
Attachment D - Recruitment Email	Attachment D - Recruitment Email.docx	01/17/2012
Attachment F - Final Mail to Non-Responders to Two Monthly Follow-ups	Attachment F - Final Mail to Non-Responders to Two Monthly Follow-ups.docx	01/17/2012
OMB Submission Form - Customer Satisfaction with AHRQ's HIE Evaluation Toolkit	OMB Submission Form - Customer Satisfaction with AHRQ's HIE Evaluation Toolkit.docx	01/17/2012

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