Information Collection

2016 CDC Healthcare Systems Scorecard (HSSC) Assessment Tool for Primary Care Practices

IC 221137 under ICR 201506-0920-003 · OMB 0920-0222.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0222 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
2016 CDC Healthcare Systems Scorecard (HSSC) Assessment Tool for Primary Care Practices	Form
Screener Att 3 Screener 040616.docx	Form
Interview Questionnaire Att 1 Questionnaire 040616.doc	Form
Demographic Sheet Att 5 Resp Data Collect.docx	Form
Scorecard 10day ltr 041816.docx Letter to Dr. Schwab	IC Document
Att 2 Invite letter.docx Advance Letter	IC Document
Att 4 Informed Consent 040616.docx Consent	IC Document
Att 6 Thank You letter.docx Thank you letter	IC Document
Att 7 Spec Consent 040616.docx Special consent	IC Document

IC Title:

2016 CDC Healthcare Systems Scorecard (HSSC) Assessment Tool for Primary Care Practices

Agency IC Tracking Number:

16ADZ

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	none	Screener	Att 3 Screener 040616.docx	Yes	Yes	Fillable Fileable
Form	none	Interview Questionnaire	Att 1 Questionnaire 040616.doc	Yes	Yes	Fillable Fileable
Form	none	Demographic Sheet	Att 5 Resp Data Collect.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: Health and Demographic Surveys Conducted in Probability Samples of the US Population

FR Citation: 49 FR 37693

Number of Respondents: 92

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

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	92	92
Annual IC Time Burden (Hours)	26	26
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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