Attachment A: Baseline Practice Assessment

Collection of Information for: Agency for Healthcare Research and Quality’s (AHRQ) Guide to Improving Patient Safety in Primary Care Settings by Engaging Patients and Families – Evaluation

Documents and Forms

Document Name Document Type
Form 1 Attachment A: Baseline Practice Assessment Form and Instruction
1 Appendix A: Baseline Practice Assessment Appendix A_ Baseline_Assessment_rev_20161031.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Attachment A: Baseline Practice Assessment	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 and Instruction	1	Appendix A: Baseline Practice Assessment	Appendix A_ Baseline_Assessment_rev_20161031.docx		No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 12	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	12	12
Annual IC Time Burden (Hours)	12	12
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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