PCMH-A Assessment Tool

The Consumer Assessment of Healthcare Providers and Systems (CAHPS) Patient-Centered Medical Home (PCMH) Items Demonstration Study.

Documents and Forms

Document Name Document Type
Form 5 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

Information Collection (IC) Details

IC Title:	PCMH-A Assessment Tool	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	5	Attachment H: PCMH-A assessment	Attachment H-PCMH-A_with prefills needed_10Jan2017-FINALdocx.docx		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 %

	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

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.