Information Collection

Questionnaire and Data Collection Testing, Evaluation, and Research for the Agency for Healthcare Research and Quality - Insurance Plans Purchased Individually

IC 234710 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⚠️ Notice: This information collection may be referencing outdated material.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 2 Questionnaire and Data Collection Testing, Evaluation, and Research for the Agency for Healthcare Research and Quality - Insurance Plans Purchased Individually	Form and Instruction
3 Attachment G – Interview Guide Attachment G - Interview Guide Insurance Plans Purchased Individually.docx	Form and Instruction
1 Initial Screening Attachment A Initial Screening Questionnaire Private Ins.docx	Form and Instruction
2 In Depth Screening Attachment B In-depth Screening Questionnaire Private Ins.docx	Form and Instruction
OMB Cover Letter.doc Cover Page	IC Document
Attachment C – Informational Letter for Participants Insurance Plans Purchased Individually.docx Attachment C – Informational Letter for Participants	IC Document
Attachment D – Participant Consent Form Insurance Plans Purchased Individually.docx Attachment D – Participant Consent Form	IC Document
Attachment E – Directions to Econometrica Facility Insurance Plans Purchased Individually.docx Attachment E – Directions to Econometrica Facility	IC Document
Attachment F - Checklist and Directions for Gathering Requested Documents Insurance Plans Purchased Individually.docx Attachment F – Checklist and Directions for Gathering Requested Documents	IC Document
Supporting Statement A Health Policy Booklets Insurance Plans Purchased Individually 031119.docx Supporting Statement	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Questionnaire and Data Collection Testing, Evaluation, and Research for the Agency for Healthcare Research and Quality - Insurance Plans Purchased Individually

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	2	In Depth Screening	Attachment B In-depth Screening Questionnaire Private Ins.docx	Yes	Yes	Fillable Fileable
Form and Instruction	1	Initial Screening	Attachment A Initial Screening Questionnaire Private Ins.docx	Yes	Yes	Fillable Fileable
Form and Instruction	3	Attachment G â Interview Guide	Attachment G - Interview Guide Insurance Plans Purchased Individually.docx	No		Paper Only

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 245

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 75 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	245	245
Annual IC Time Burden (Hours)	28	28
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Cover Page	OMB Cover Letter.doc	01/11/2019
Attachment C â Informational Letter for Participants	Attachment C â Informational Letter for Participants Insurance Plans Purchased Individually.docx	01/11/2019
Attachment D â Participant Consent Form	Attachment D â Participant Consent Form Insurance Plans Purchased Individually.docx	01/11/2019
Attachment E â Directions to Econometrica Facility	Attachment E â Directions to Econometrica Facility Insurance Plans Purchased Individually.docx	01/11/2019
Attachment F â Checklist and Directions for Gathering Requested Documents	Attachment F - Checklist and Directions for Gathering Requested Documents Insurance Plans Purchased Individually.docx	01/11/2019
Supporting Statement	Supporting Statement A Health Policy Booklets Insurance Plans Purchased Individually 031119.docx	04/08/2019

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