Questionnaire and Data Collection Testing, Evaluation, and Research for the Agency for Healthcare Research and Quality

Forms and Documents

Document Name	Status
Form B1 Cognitive Testing of the Medical Expenditure Panel Survey (MEPS) Health Insurance Verification Module Form and Instruction	New
Form 3 Identifying, Assessing, and Balancing Competing Risks of Multiple Hospital-Acquired Conditions (HACs) Form and Instruction	New
Form 2 Identifying, Assessing, and Balancing Competing Risks of Multiple Hospital-Acquired Conditions (HACs) Form and Instruction	New
Form 1 Identifying, Assessing, and Balancing Competing Risks of Multiple Hospital-Acquired Conditions (HACs) Form and Instruction	New
Form 2 Environmental Scan for Guide to Improving Patient Safety in Primary Care Settings by Engaging Patients and Families Form and Instruction	New
Supporting Statement Part B -- Generic Pretesting Clearance 2014.doc Supporting Statement B	2014-09-05
Attachment A -- Healthcare Research and Quality Act of 1999.pdf Supplementary Document	2011-03-31
Attachment B -- Examples.doc Supplementary Document	2011-03-31
Supporting Statement Part A -- FINAL1 Generic Pretesting Clearance 2014.doc Supporting Statement A	2014-11-04

IC Document Collections

IC ID	Document Title	Status
226530	Cognitive Testing of the Medical Expenditure Panel Survey (MEPS) Health Insurance Verification Module Form and Instruction	New
226380	Identifying, Assessing, and Balancing Competing Risks of Multiple Hospital-Acquired Conditions (HACs) Form and Instruction	New
226351	Identifying, Assessing, and Balancing Competing Risks of Multiple Hospital-Acquired Conditions (HACs) Form and Instruction	New
226350	Identifying, Assessing, and Balancing Competing Risks of Multiple Hospital-Acquired Conditions (HACs) Form and Instruction	New
219183	Environmental Scan for Guide to Improving Patient Safety in Primary Care Settings by Engaging Patients and Families Form and Instruction	New

ICR Details

OMB Control No: 0935-0124	ICR Reference No: 201409-0935-002
Status: Historical Active	Previous ICR Reference No: 201104-0935-002
Agency/Subagency: HHS/AHRQ	Agency Tracking No:
Title: Questionnaire and Data Collection Testing, Evaluation, and Research for the Agency for Healthcare Research and Quality
Type of Information Collection: Reinstatement without change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 11/12/2014
	Date Received in OIRA: 09/09/2014
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2017	36 Months From Approved
Responses	4,600	0	0
Time Burden (Hours)	2,967	0	0
Cost Burden (Dollars)	0	0	0

---

Abstract: Work conducted under this clearance is intended to improve AHRQ's current data collections by developing new surveys and revising surveys and to test survey instruments more quickly.

---

Authorizing Statute(s): None

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 30848	05/29/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 51336	08/28/2014
Did the Agency receive public comments on this ICR? Yes

---

Number of Information Collection (IC) in this ICR: 5

IC Title	Form No.	Form Name
Cognitive Testing of the Medical Expenditure Panel Survey (MEPS) Health Insurance Verification Module	C1, B1	Attachment B – Screening Questionnaire ,   Attachment C1 - Cognitive Interview Guide and Questionnaire
Identifying, Assessing, and Balancing Competing Risks of Multiple Hospital-Acquired Conditions (HACs)	2	Attachment B – HAC Risk Dashboard Tool Low-Fidelity Prototype Evaluation Focus Group Guide
Identifying, Assessing, and Balancing Competing Risks of Multiple Hospital-Acquired Conditions (HACs)	3	Attachment C – HAC Risk Dashboard Tool Key Informant Interview Guide
Environmental Scan for Guide to Improving Patient Safety in Primary Care Settings by Engaging Patients and Families	6, 4, 2, 8, 7, 1, 3, 5	Attachment B: Key Informant Interview Guide- In-person ,   Attachment D: Interview Guide for Case Study Development- In-person ,   Attachment F: Interview Guide for Patients/Family Members/Caregivers- In-person ,   Attachment H: Interview Guide for Primary Care Practice Staff and Physicians- In-person ,   Attachment A: Key Informant Interview Guide- Telephone ,   Attachment C: Interview Guide for Case Study Development- Telephone ,   Attachment E: Interview Guide for Patients/Family Members/Caregivers- Telephone ,   Attachment G: Interview Guide for Primary Care Practice Staff and Physicians- Telephone
Identifying, Assessing, and Balancing Competing Risks of Multiple Hospital-Acquired Conditions (HACs)	1	Attachment A – HAC Risk Dashboard Tool Information Needs Identification Focus Group Guide

---

ICR Summary 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	4,600	0	0	0	0	4,600
Annual Time Burden (Hours)	2,967	0	0	0	0	2,967
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

---

Annual Cost to Federal Government: $703,848

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

---

Common Form ICR:  No

---

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: 09/09/2014

---