Personal Health Record (PHR) User Survey

Testing Experience and Functional Tools Demonstration: Personal Health Record (PHR) User Survey (CMS-10623)

Documents and Forms

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

Information Collection (IC) Details

IC Title:	Personal Health Record (PHR) User Survey	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection 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 %

	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

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.