Information Collection

PCMH-A Assessment Tool

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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 5 Attachment H: PCMH-A assessment PCMH-A Assessment Tool	Form and Instruction
5 Attachment H: PCMH-A assessment Attachment H-PCMH-A_with prefills needed_10Jan2017-FINALdocx.docx	Form and Instruction
Attachment I 60 Day FRN.pdf Attachment I: Federal Register Notice	IC Document
Attachment D-PhysicianPCMHLeaderCoverLetter_11Jan2017_FINAL.docx Attachment D: Physician/PCMH Leader Cover Letter	IC Document
Attachment E-AHRQ Endorsement-signed_FINAL.pdf Attachment E: AHRQ Endorsement Letter	IC Document
Attachment F-INFO SHEET_10Jan2017_FINAL.docx Attachment F: Information Sheet Sent with Cover Letter	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	5				No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 150

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	150	150
Annual IC Time Burden (Hours)	25	25
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment I: Federal Register Notice		01/19/2017
Attachment D: Physician/PCMH Leader Cover Letter		01/19/2017
Attachment E: AHRQ Endorsement Letter		01/19/2017
Attachment F: Information Sheet Sent with Cover Letter		01/19/2017

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

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