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

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⚠️ Notice: This information collection may be referencing outdated material.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

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:

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 – Interview Guide	Attachment G - Interview Guide Insurance Plans Purchased Individually.docx	No		Paper Only

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 %

	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

Title	Document	Date Uploaded
Cover Page	OMB Cover Letter.doc	01/11/2019
Attachment C – Informational Letter for Participants	Attachment C – Informational Letter for Participants Insurance Plans Purchased Individually.docx	01/11/2019
Attachment D – Participant Consent Form	Attachment D – Participant Consent Form Insurance Plans Purchased Individually.docx	01/11/2019
Attachment E – Directions to Econometrica Facility	Attachment E – Directions to Econometrica Facility Insurance Plans Purchased Individually.docx	01/11/2019
Attachment F – 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.