Screening Questionnaire Instructions

DEPARTMENT OF HEALTH AND HUMAN SERVICES

OFFICE OF THE SECRETARY

Voice – (202) 619-0403 TDD – (202) 619-2357 FAX – (202) 619-3818
http://www.hhs.gov/ocr

Office for Civil Rights
200 Independence Ave., SW; RM 509F
Washington, DC 20201

November 18, 2015

TO:

OMB Desk Officer

CC:

Sherette Funn, OCIO / OS Report Clearance Officer

FROM:

Zinethia Clemmons, Sr. Health Information Privacy Specialist

RE:

Non-substantive change request for OMB control #0945-0007

Non-substantive change request for OMB control #0945-0007
HHs is requesting approval for a non-substantive change to the information collection
assigned OMB control number 0945-0007, which expires on March 31, 2018.
This Pre-Audit Screening Questionnaire will enable OCR to determine characteristics
about a given entity in relation to the overall sample pool of potential auditees and
select the entities that best fit OCR criteria for OCR’s desired auditee population.
Generally, OCR is looking to obtain an appropriate mix of size and complexity of
entities to be audited.
Proposed Adjustment to the Screening Questionnaire
OCR requests permission to update the form by asking business associate respondents
to submit an approximate number of covered entities for which they provide covered
functions as well as an approximation of their total revenue from business associate
activities. We are making this change because entities may not be able to provide exact
amounts. In addition, we no longer require business associates to provide the number
of each type of covered entity with which they have business associate agreements,
thus, we are removing this question altogether.

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No Impact on Respondent Burden
As described above, these non-substantial technical modifications to the questionnaire
do not require an adjustment to the respondent burden associated with this data
collection effort.
The table below shows the data collection burden, which remains unchanged from the
data collection burden previously approved by OMB on March 31, 2015.

Type of
Respondent

Covered
Entity
Administrator
or Privacy
Officer(s)
Business
Associate
Administrator
Total

Form
Name

No. of
Respondents

OCR Pre-Audit
Screening
questionnaire

500

OCR Pre-Audit
Screening
questionnaire

200

No.
Average
Responses Burden per
per
Response
Respondent (in hours)
1
0.5
(or 30 mins)

1

0.5
(or 30 mins)

Total
Burden
Hours
250

100

350