Information Collection

2015 National Electronic Health Records Survey

IC 215492 under ICR 201205-0920-001 · OMB 0920-0222.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0222 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
2015 National Electronic Health Records Survey	Form
National Electronic Health Records Survey 2015 Attach 1- Qnne.docx	Form
Screener Attach 3 - Telephone screener 021215.docx	Form and Instruction
Respondent Data Sheet Attach 5 - Resp Data Sheet.docx	Form
NEHRS 10-day letter 022415 sig.docx Leter to Dr. Schwab	IC Document
Attach 2 - Invitational letter.docx Invitational Letter	IC Document
Attach 4- Informed consent 021215.docx Consent for interviews	IC Document
Attach 6 - Special Consent.docx Consent to Record	IC Document

IC Title:

2015 National Electronic Health Records Survey

Agency IC Tracking Number:

15QR

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	none	National Electronic Health Records Survey 2015	Attach 1- Qnne.docx	Yes	Yes	Fillable Fileable
Form and Instruction	none	Screener	Attach 3 - Telephone screener 021215.docx	Yes	Yes	Fillable Fileable
Form	none	Respondent Data Sheet	Attach 5 - Resp Data Sheet.docx	No		Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: Health and Demographic Surveys Conducted in Probability Samples of US Population

FR Citation: 49 FR 37693

Number of Respondents: 134

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	134	134
Annual IC Time Burden (Hours)	57	57
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Leter to Dr. Schwab	NEHRS 10-day letter 022415 sig.docx	03/02/2015
Invitational Letter	Attach 2 - Invitational letter.docx	03/02/2015
Consent for interviews	Attach 4- Informed consent 021215.docx	03/02/2015
Consent to Record	Attach 6 - Special Consent.docx	03/02/2015

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