OMB.report

Federal forms, ICRs, and supporting documents

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.

Documents and Forms

Documents and forms in this information collection
Document NameDocument Type
Form 3
Attachment G – Interview Guide Questionnaire and Data Collection Testing, Evaluation, and Research for the Agency for Healthcare Research and Quality - Insurance Plans Purchased Individually		 Form and Instruction
Form 1
Initial Screening Questionnaire and Data Collection Testing, Evaluation, and Research for the Agency for Healthcare Research and Quality - Insurance Plans Purchased Individually		 Form and Instruction
Form 2
In Depth Screening 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)

layout table

Information Collection Instruments:
table that charts list of instruments
Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction 3 No   Paper Only
Form and Instruction 1 Yes Yes Fillable Fileable
Form and Instruction 2 Yes Yes Fillable Fileable

Federal Enterprise Architecture Business Reference Module


table that charts list of burden
  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 245 0 245 0 0 0
Annual IC Time Burden (Hours) 28 0 28 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Documents for IC
table that charts IC Documents
Title Document Date Uploaded
Cover Page 01/11/2019
Attachment C – Informational Letter for Participants 01/11/2019
Attachment D – Participant Consent Form 01/11/2019
Attachment E – Directions to Econometrica Facility 01/11/2019
Attachment F – Checklist and Directions for Gathering Requested Documents 01/11/2019
Supporting Statement 04/08/2019
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
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