Advancing the Collection and Use of Patient –Reported Outcomes through Health Information Technology

Questionnaire and Data Collection Testing, Evaluation, and Research for the Agency for Healthcare Research and Quality

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0935-0124 can be found here:

Documents and Forms

Document Name Document Type
Form 1 Advancing the Collection and Use of Patient –Reported Outcomes through Health Information Technology Form and Instruction
1 Attachment A. PROMIS Item Bank V2.0 Attachment A_Promis Items_112818.docx Form and Instruction
2 Process Usage Worksheet (Patients) Attachment C_Patient Process Usage Worksheet_112818.docx Form and Instruction
3 Attachment D: Process Usage Worksheet (Providers) Attachment D_Provider Process Usage Worksheet_112818.docx Form and Instruction
Attachment B_Training Materials_112818.docx Attachment B: Training Materials IC Document
Supporting Statement_112818.doc Supporting Statement IC Document
OMB Cover Letter.docx.doc Cover Letter IC Document

Information Collection (IC) Details

IC Title:	Advancing the Collection and Use of Patient –Reported Outcomes through Health Information Technology	Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1	Attachment A. PROMIS Item Bank V2.0	Attachment A_Promis Items_112818.docx	Yes	Yes	Fillable Fileable
Form and Instruction	2	Process Usage Worksheet (Patients)	Attachment C_Patient Process Usage Worksheet_112818.docx	Yes	Yes	Fillable Fileable
Form and Instruction	3	Attachment D: Process Usage Worksheet (Providers)	Attachment D_Provider Process Usage Worksheet_112818.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 216	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	899	899
Annual IC Time Burden (Hours)	120	120
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Attachment B: Training Materials	Attachment B_Training Materials_112818.docx	11/29/2018
Supporting Statement	Supporting Statement_112818.doc	11/29/2018
Cover Letter	OMB Cover Letter.docx.doc	11/29/2018

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