Form 1 User Self-ID Registration Questions

Form Approved

OMB No. 0955-0003

Exp. Date 10/31/2014

Cornell Planning Room Project - User Self-ID Registration Questions

As site users register to participate on PlanningRoom.org the drop-down menu should include the following:

Have you ever commented on federal health IT policy and programs?

Yes

No

Not sure

Please select which category best describes your interest in this proposed strategy (can pick > one):

I am a patient, consumer or caregiver

Health Care Provider/Professional

I am a healthcare provider – Hospital-based

I am a healthcare provider – Physician practice-based

I am a CMO/CMIO

I am a healthcare provider – Other

Industry

I work for a trade or professional organization, medical society or board

I work for a health plan or purchaser

I work for a health IT vendor or service provider

Other

I work for a consumer organization

I am a researcher or scientist

I am a health navigator or coach

I am a health policy professional

I am an attorney

I am a government employee

Other/Miscellaneous (Please describe) [FREE TEXT BOX]

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0955-0003. The time required to complete this information collection is estimated to average >1 hour per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer