Demonstration of Health Literacy Universal Precautions Toolkit

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form Form #17 Practice Staff Member Interview - Post-implementation	Form and Instruction	New	Available
Form Form #16 Health Literacy Team Member Interview - Post-implementation	Form and Instruction	New	Available
Form Form #15 Health Literacy Team Leader Interview - Post-implementation	Form and Instruction	New	Available
Form Form #14 Health Literacy Team Leader Interview - Pre-implementation	Form and Instruction	New	Available
Form Form #13 Check-in Phone Calls	Form and Instruction	New	Available
Form Form #12 Health Literacy Team Leader Survey - Post-implementation	Form and Instruction	New	Available
Form Form #11 Health Literacy Team Leader Survey - Pre-implementation	Form and Instruction	New	Available
Form Form #10 Practice Staff Survey - Post-implementation	Form and Instruction	New	Available
Form Form #9 Practice Staff Survey - Pre-implementation	Form and Instruction	New	Available
Form Form #8 Medication Review Form	Form and Instruction	New	Available
Form Form #7 Survey Using Items from the Consumer Assessment of Healthcare Providers and Systems (CAHPS)	Form and Instruction	New	Available
Form Form #6 Patient Survey	Form and Instruction	New	Available
Form Form #5 Webinar/Orientation	Form and Instruction	New	Available
Form Form #4 Implementation Tracking Form	Form and Instruction	New	Available
Form Form #3 Health Literacy Assessment Questions	Form and Instruction	New	Available
Form Form #2 Follow-up Recruitment Calls	Form and Instruction	New	Available
Form Form #1 Practice Screening Calls	Form and Instruction	New	Available
Supporting Statement Part B--Demonstration of Health Literacy Precautions Toolkit 09-14-2012.doc	Supporting Statement B	Uploaded 2012-09-20	Available
Attachment V -- Federal Register Notice.pdf	Supplementary Document	Uploaded 2012-05-30	Available
Attachment P -- Consent Form.doc	Supplementary Document	Uploaded 2012-05-30	Available
Attachment H -- Project Team Review of Practice HL Environment.docx	Supplementary Document	Uploaded 2012-05-30	Available
Attachment B -- Recruitment Email.docx	Supplementary Document	Uploaded 2012-05-30	Available
Attachment A -- Health Literacy Universal Precautions Toolkit.pdf	Supplementary Document	Uploaded 2012-05-30	Available
Attachment I.3 -- Patient Survey Cover memo-Paper.docx	Supplementary Document	Uploaded 2012-05-30	Available
Attachment I.2 -- Patient Survey Cover Memo-Tablet.docx	Supplementary Document	Uploaded 2012-05-30	Available
Supporting Statement Part A--Demonstration of Health Literacy Precautions Toolkit 09-14-2012.doc	Supporting Statement A	Uploaded 2012-09-20	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
202549	Practice Staff Member Interview - Post-implementation	Form and Instruction	New
202548	Health Literacy Team Member Interview - Post-implementation	Form and Instruction	New
202547	Health Literacy Team Leader Interview - Post-implementation	Form and Instruction	New
202546	Health Literacy Team Leader Interview - Pre-implementation	Form and Instruction	New
202545	Check-in Phone Calls	Form and Instruction	New
202544	Health Literacy Team Leader Survey - Post-implementation	Form and Instruction	New
202543	Health Literacy Team Leader Survey - Pre-implementation	Form and Instruction	New
202542	Practice Staff Survey - Post-implementation	Form and Instruction	New
202541	Practice Staff Survey - Pre-implementation	Form and Instruction	New
202540	Medication Review Form	Form and Instruction	New
202539	Survey Using Items from the Consumer Assessment of Healthcare Providers and Systems (CAHPS)	Form and Instruction	New
202538	Patient Survey	Form and Instruction	New
202537	Webinar/Orientation	Form and Instruction	New
202536	Implementation Tracking Form	Form and Instruction	New
202535	Health Literacy Assessment Questions	Form and Instruction	New
202534	Follow-up Recruitment Calls	Form and Instruction	New
202533	Practice Screening Calls	Form and Instruction	New

ICR Details

OMB Control No: 0935-0202	ICR Reference No: 201205-0935-003
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/AHRQ	Agency Tracking No:
Title: Demonstration of Health Literacy Universal Precautions Toolkit
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: 10/12/2012
	Date Received in OIRA: 05/31/2012
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2014	12 Months From Approved
Responses	3,974	0	0
Time Burden (Hours)	1,469	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The purpose of this demonstration project is to explore whether the Toolkit helps motivated practices to make changes intended to improve communication with and support for patients of all literacy levels. Twelve primary care practices will be recruited to implement at least four tools from the Health Literacy Universal Precautions Toolkit. The project team will provide participating practices with limited technical assistance throughout the implementation period. Data regarding the assistance provided will contribute to the team's assessment of the ease with which specific tools can be implemented and will provide insight into additional resources and guidance that might be valuable to add to the Toolkit.

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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:
	77 FR 14373	03/09/2012
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 30007	05/21/2012
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 17

table that charts list of burden

IC Title	Form No.	Form Name
Practice Screening Calls	Form #1	Practice Screening Calls
Follow-up Recruitment Calls	Form #2	Follow-up Recruitment Calls
Health Literacy Assessment Questions	Form #3	Health Literacy Assessment Questions
Implementation Tracking Form	Form #4	Implementation Tracking Form
Webinar/Orientation	Form #5	Webinar/Orientation Presentation
Patient Survey	Form #6	Patient Survey
Survey Using Items from the Consumer Assessment of Healthcare Providers and Systems (CAHPS)	Form #7	Survey Using Items from the Consumer Assessment of Healthcare Providers and Systems (CAHPS)
Medication Review Form	Form #8	Medication Review Form
Practice Staff Survey - Pre-implementation	Form #9	Practice Staff Survey - Pre-implementation
Practice Staff Survey - Post-implementation	Form #10	Practice Staff Survey - Post-implementation
Health Literacy Team Leader Survey - Pre-implementation	Form #11	Health Literacy Team Leader Survey - Pre-implementation
Health Literacy Team Leader Survey - Post-implementation	Form #12	Health Literacy Team Leader Survey - Post-implementation
Check-in Phone Calls	Form #13	Check-in Phone Calls
Health Literacy Team Leader Interview - Pre-implementation	Form #14	Health Literacy Team Leader Interview - Pre-implementation
Health Literacy Team Leader Interview - Post-implementation	Form #15	Health Literacy Team Leader Interview - Post-implementation
Health Literacy Team Member Interview - Post-implementation	Form #16	Health Literacy Team Member Interview - Post-implementation
Practice Staff Member Interview - Post-implementation	Form #17	Practice Staff Member Interview - Post-implementation

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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	3,974	0	0	3,974	0	0
Annual Time Burden (Hours)	1,469	0	0	1,469	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: $784,910

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: 05/31/2012

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