Pre-test of an Assisted Living Consensus Instrument

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form Form #2 Pre-test	Form and Instruction	New	Available
Form Form #1 Telephone verification	Form and Instruction	New	Available
Supporting Statement Part B -- Pretest of an Assisted Living Consensus Instrument_11-22-2011.doc	Supporting Statement B	Uploaded 2011-11-22	Available
Attachment A -- Healthcare Research and Quality Act of 1999.pdf	Supplementary Document	Uploaded 2011-07-28	Available
Attachment E -- Federal Register Notice.pdf	Supplementary Document	Uploaded 2011-07-28	Available
Attachment G -- Confidentiality Agreement for Contractor Staff.doc	Supplementary Document	Uploaded 2011-07-28	Available
Attachment F -- Individual Participants of the ALDC.pdf	Supplementary Document	Uploaded 2011-07-28	Available
Attachment B -- Organizational Participants of the ALDC.docm	Supplementary Document	Uploaded 2011-07-28	Available
Attachment H -- Recruitment Letter, Brochure & Followup Postcards.docm	Supplementary Document	Uploaded 2011-07-28	Available
Supporting Statement Part A -- Pretest of an Assisted Living Consensus Instrument 11-22-2011.docx	Supporting Statement A	Uploaded 2011-11-22	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
198731	Pre-test	Form and Instruction	New
198730	Telephone verification	Form and Instruction	New

ICR Details

OMB Control No: 0935-0188	ICR Reference No: 201108-0935-001
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/AHRQ	Agency Tracking No:
Title: Pre-test of an Assisted Living Consensus Instrument
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: 12/12/2011
	Date Received in OIRA: 08/02/2011
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2012	12 Months From Approved
Responses	476	0	0
Time Burden (Hours)	85	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: Using a consensus-based process and in partnership with the Center for Excellence in Assisted Living, AHRQ has developed a data collection tool that will collect uniform information about individual assisted living facilities (ALFs) in the United States to increase the value of healthcare for consumers by helping them make informed choices when selecting an ALF. Included in the development process was a voluntary committee of national representatives of Assisted Living consumers and researchers. The purpose of this project is to pretest the data collection tool.

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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 27323	05/11/2011
30-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 44927	07/27/2011
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 2

table that charts list of burden

IC Title	Form No.	Form Name
Telephone verification	Form #1	Telephone Verification Script
Pre-test	Form #2	Assisted Living Provider Information Tool for Consumer Education

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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	476	0	0	476	0	0
Annual Time Burden (Hours)	85	0	0	85	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 is a new Information Collection Request.

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Annual Cost to Federal Government: $439,552

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: 08/02/2011

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