Information Collection

BHIT Survey

IC 216733 under ICR 201505-0930-001 · OMB 0930-0352.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form BHITS BHIT Survey	Form and Instruction
BHITS BHITS Attachment 1_Survey Questions_05_28_15.docx	Form and Instruction
Attachment 2_Data Dictionary-Key-Terms-Definitions_2_27_15.docx Data Dictionary	IC Document
Attachment 3_Survey Question Crosswalk to Research Question and Domain_052215.docx Survey Question Crosswalk	IC Document
Attachment 4_Pilot_Protocol_Schedule_Documents-2_27_15.docx Pilot_Protocol	IC Document
Attachment 5_GranteeLetter_2_27_15.doc Grantee Letter	IC Document
Attachment 6_ScrennShots._5_27_15pdf Screnn Shots	IC Document

IC Title:

BHIT Survey

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	BHITS	BHITS	Attachment 1_Survey Questions_05_28_15.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 374

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	374	374
Annual IC Time Burden (Hours)	150	150
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Data Dictionary	Attachment 2_Data Dictionary-Key-Terms-Definitions_2_27_15.docx	05/28/2015
Survey Question Crosswalk	Attachment 3_Survey Question Crosswalk to Research Question and Domain_052215.docx	05/28/2015
Pilot_Protocol	Attachment 4_Pilot_Protocol_Schedule_Documents-2_27_15.docx	05/28/2015
Grantee Letter	Attachment 5_GranteeLetter_2_27_15.doc	05/28/2015
Screnn Shots	Attachment 6_ScrennShots._5_27_15pdf	05/28/2015

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