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

NCHS Questionnaire Design Research Laboratory

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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

Information Collection (IC) Details

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:

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 %

	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.