Patient Semi-Structured Interviews

Using Health Information Technology in Practice Redesign: Impact of Health Information Technology on Workflow

Documents and Forms

Document Name Document Type
Form Form #4 Patient Semi-Structured Interviews Form and Instruction
Form #4 Patient Interview Guide Attachment F -- Patient Interview Guide.doc Form and Instruction
Attachment M -- Consent Form to Participate in Patient Interview.docx Attachment M -- Consent Form to Participate in Patient Interview IC Document

Information Collection (IC) Details

IC Title:	Patient Semi-Structured Interviews	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	Form #4	Patient Interview Guide	Attachment F -- Patient Interview Guide.doc		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 64	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	64	64
Annual IC Time Burden (Hours)	64	64
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Attachment M -- Consent Form to Participate in Patient Interview	Attachment M -- Consent Form to Participate in Patient Interview.docx	01/11/2013

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