Form #10 Form #10 Draft CV Checklist Evaluation

Form Approved
OMB No. 0935-XXXX
Exp. Date XX/XX/20XX

Attachment M

Checklist Evaluation

1. Is the list complete (no significant omissions)?

2. Are there incomplete items?

3. Do any items overlap?

4. Are there unclear items?

5. Is the list concise?

6. Is it easy to use?

7. How long did it take you to use the checklist?

8. In general, can the checklist be completed in a reasonably brief period of time?

9. Does using the checklist fit the flow of work?

10. Are the items in the order you would like them? How might you reorder them?

11. Would you prefer to read each step, then do it or do the steps from memory, then pause and check?

12. Does the checklist cover costs to society of choosing particular types of investigation, treatment and recovery

Public reporting burden for this collection of information is estimated to average 30 minutes per response, the estimated time required to complete the survey. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-XXXX) AHRQ, 540 Gaither Road, Room # 5036, Rockville, MD 20850.