Information Collection

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

IC 234239 under ICR 201708-0935-002 · OMB 0935-0124.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
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

IC Title:

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

Agency IC Tracking Number:

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	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 %

table that charts list of burden
	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

table that charts IC Documents
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.