Appendix C: Interview Guide- Baseline Practice Readiness

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 3 Appendix C: Interview Guide- Baseline Practice Readiness Form and Instruction
3 Appendix C: Interview Guide- Baseline Practice Readiness Appendix C_ ChangeReadiness .docx Form and Instruction

Information Collection (IC) Details

IC Title:	Appendix C: Interview Guide- Baseline Practice Readiness	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	3	Appendix C: Interview Guide- Baseline Practice Readiness	Appendix C_ ChangeReadiness .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)	9	9
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.