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⚠️ Notice: This information collection may be referencing outdated material.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

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

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.