2015 National Electronic Health Records Survey

NCHS Questionnaire Design Research Laboratory

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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

Information Collection (IC) Details

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:

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 %

	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

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.