Information Collection

Personal Health Record (PHR) User Survey

IC 223740 under ICR 201609-0938-030 · OMB 0938-1324.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10623 Personal Health Record (PHR) User Survey	Form
CMS-10623 Personal Health Record (PHR) User Survey Appendix A - PHR User Survey [rev 10-04-2016 by OSORA PRA].docx	Form
CMS-10623 Consent Form Appendix C - Consent Form_508.docx	Form and Instruction
Appendix B - TEFT PHR Data Security Plan_September 2016_508.docx Data Security Plan	IC Document

IC Title:

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	CMS-10623	Personal Health Record (PHR) User Survey	Appendix A - PHR User Survey [rev 10-04-2016 by OSORA PRA].docx		Yes	Yes	Fillable Printable
Form and Instruction	CMS-10623	Consent Form	Appendix C - Consent Form_508.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 576

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	576	576
Annual IC Time Burden (Hours)	190	190
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Data Security Plan	Appendix B - TEFT PHR Data Security Plan_September 2016_508.docx	10/03/2016

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