OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

PCMH-A Assessment Tool

IC 225266 under ICR 201611-0935-001 · OMB 0935-0236.

Documents and Forms
Document Name
Document Type
Form and Instruction
Form and Instruction
IC Document
IC Document
IC Document
IC Document
Information Collection (IC) Details

View Information Collection (IC)

PCMH-A Assessment Tool
 
No New
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction 5 Attachment H: PCMH-A assessment Attachment H-PCMH-A_with prefills needed_10Jan2017-FINALdocx.docx No   Paper Only

Health Health Care Services

 

150 0
   
Private Sector Businesses or other for-profits
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 150 0 150 0 0 0
Annual IC Time Burden (Hours) 25 0 25 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Attachment I: Federal Register Notice Attachment I 60 Day FRN.pdf 01/19/2017
Attachment D: Physician/PCMH Leader Cover Letter Attachment D-PhysicianPCMHLeaderCoverLetter_11Jan2017_FINAL.docx 01/19/2017
Attachment E: AHRQ Endorsement Letter Attachment E-AHRQ Endorsement-signed_FINAL.pdf 01/19/2017
Attachment F: Information Sheet Sent with Cover Letter Attachment F-INFO SHEET_10Jan2017_FINAL.docx 01/19/2017
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.