Information Collection

Customer Satisfaction with the AHRQ Videonovela Aprende a vivir.

IC 205936 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⚠️ Notice: This information collection may be referencing outdated material.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 the AHRQ Videonovela Aprende a vivir.	Form and Instruction
Form #1 Attachment A -- Patient Questionnaire - Spanish Version Attachment A -- Patient Questionnaire -- Spanish Version.docx	Form and Instruction
Form #2 Attachment C - Health Care Professional Questionnaire Attachment C -- Healthcare Professional Questionnaire.docx	Form and Instruction
Attachment B -- Patient Questionnaire -- English Version.docx Attachment B -- Patient Questionnaire -- English Version	IC Document
Attachment D -- Healthcare Professional Cover Letter.docx Attachment D -- Healthcare Professional Cover Letter	IC Document
OMB Submission Form--Customer Satisfaction with the AHRQ Videonovela Aprende a vivir.docx OMB Submission Form--Customer Satisfaction with the AHRQ Videonovela Aprende a vivir	IC Document

IC Title:

Customer Satisfaction with the AHRQ Videonovela Aprende a vivir.

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	Attachment A -- Patient Questionnaire - Spanish Version	Attachment A -- Patient Questionnaire -- Spanish Version.docx		Yes	Yes	Paper Only
Form and Instruction	Form #2	Attachment C - Health Care Professional Questionnaire	Attachment C -- Healthcare Professional Questionnaire.docx		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 210

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	210	0	0	0	0	0
Annual IC Time Burden (Hours)	35	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 B -- Patient Questionnaire -- English Version	Attachment B -- Patient Questionnaire -- English Version.docx	02/26/2013
Attachment D -- Healthcare Professional Cover Letter	Attachment D -- Healthcare Professional Cover Letter.docx	02/26/2013
OMB Submission Form--Customer Satisfaction with the AHRQ Videonovela Aprende a vivir	OMB Submission Form--Customer Satisfaction with the AHRQ Videonovela Aprende a vivir.docx	02/26/2013

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