Information Collection

Formative Research to Identify Common and Unique Barriers to the Exchange of Hospitalization and ED Data

IC 237140 under ICR 201610-0920-009 · OMB 0920-1154.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1154 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Formative Research to Identify Common and Unique Barriers to the Exchange of Hospitalization and ED Data	Form
Survey AttA2_Survey instrument (screenshots).pdf	Form
Survey - word AttA1_Survey Instrument (word).docx	Form
Survey prenotice AttB1_Prenotice.DOCX	Form
GenICRequest.pdf genIC Request	IC Document
AttB2_Survey Invitation Email.DOCX Survey Invitation	IC Document
AttB3_Reminder Email.docx Reminder Email	IC Document
AttB4_Survey Closing Email.DOCX Survey Closing Email	IC Document
AttC_RDF.pdf Research Determination	IC Document
SSA_Formative Research to Identify Common and ED Data.docx Supporting Statement A	IC Document
SSB_Formative Research to Identify Common and ED Data.docx Supporting Statement B	IC Document

IC Title:

Formative Research to Identify Common and Unique Barriers to the Exchange of Hospitalization and ED Data

Agency IC Tracking Number:

0920-1154-19BEA

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	Survey	AttA2_Survey instrument (screenshots).pdf	Yes	Yes	Fillable Fileable
Form	none	Survey - word	AttA1_Survey Instrument (word).docx	Yes	Yes	Fillable Fileable
Form	none	Survey prenotice	AttB1_Prenotice.DOCX	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 52

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

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	52	52
Annual IC Time Burden (Hours)	113	113
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
genIC Request	GenICRequest.pdf	07/29/2019
Survey Invitation	AttB2_Survey Invitation Email.DOCX	07/29/2019
Reminder Email	AttB3_Reminder Email.docx	07/29/2019
Survey Closing Email	AttB4_Survey Closing Email.DOCX	07/29/2019
Research Determination	AttC_RDF.pdf	07/29/2019
Supporting Statement A	SSA_Formative Research to Identify Common and ED Data.docx	07/29/2019
Supporting Statement B	SSB_Formative Research to Identify Common and ED Data.docx	07/29/2019

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