Information Collection

Electronic Clinical Quality Measure Development

IC 211483 under ICR 201208-0955-005 · OMB 0955-0005.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0955-0005 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
0955-0005 Facilitator question guide 4_02_14.doc	Other-questionaire
0955-0005_Patient Focus Group Overview Guide_CHF_04 02 2014 (3).docx	Instruction
0955-0005 instructions_Patient Recruitment Protocols _03 25 2014.docx	Instruction
0955-0005 Letter, Agenda, Overview 3_14_14.doc Letter	IC Document
0955-0005 PilotSitePowerPoint 3_14_14.ppt Pilot Site	IC Document
0955-0005 Informed Consent PFG_CHF Goals_03 19 2014 clean (3).docx consent	IC Document
ONC HITECH_Fast-Track-PRA-Submission-Short-Form_FSACHF_2014_05_13.doc Electronic Clinical Quality Measure Development Supporting Statement	IC Document

IC Title:

Electronic Clinical Quality Measure Development

Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Instrument File	Available Electronically?	Electronic Capability
Other-questionaire	0955-0005 Facilitator question guide 4_02_14.doc	No	Paper Only
Instruction	0955-0005_Patient Focus Group Overview Guide_CHF_04 02 2014 (3).docx	No	Printable Only
Instruction	0955-0005 instructions_Patient Recruitment Protocols _03 25 2014.docx	No	Printable Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 100

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	100	100
Annual IC Time Burden (Hours)	200	200
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Letter	0955-0005 Letter, Agenda, Overview 3_14_14.doc	05/01/2014
Pilot Site	0955-0005 PilotSitePowerPoint 3_14_14.ppt	05/01/2014
consent	0955-0005 Informed Consent PFG_CHF Goals_03 19 2014 clean (3).docx	05/01/2014
Electronic Clinical Quality Measure Development Supporting Statement	ONC HITECH_Fast-Track-PRA-Submission-Short-Form_FSACHF_2014_05_13.doc	05/23/2014

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