Information Collection

EHR data (Cohorts 1, 2, and 3)

IC 227723 under ICR 201707-0935-003 · OMB 0935-0238.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0935-0238 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Att L Clinical measure instructions.docx	Instruction
Att K Clinical measure template and data dictionary.pdf Attachment K: Clinical measures template for EHR data extracts	IC Document

IC Title:

EHR data (Cohorts 1, 2, and 3)

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
Instruction			Att L Clinical measure instructions.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 334

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	4,008	4,008
Annual IC Time Burden (Hours)	4,008	4,008
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment K: Clinical measures template for EHR data extracts	Att K Clinical measure template and data dictionary.pdf	07/26/2017

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