Information Collection

Field Test of Low Literacy Version of CAHPS Clinician and Group Survey

IC 235470 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⚠️ Notice: This information collection may be referencing outdated material.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 Field Test of Low Literacy Version of CAHPS Clinician and Group Survey	Form and Instruction
1 CG-CAHPS EZ /CG-CAHPS - English Attachment A_Updated_06172019.pdf	Form and Instruction
2 CG-CAHPS EZ /CG-CAHPS - Spanish Attachment B.pdf	Form and Instruction
OMB Cover Letter.docx.doc Cover Letter	IC Document
Attachment B.pdf Supporting Statement Part B	IC Document
CAHPS EZ OMB Statement A 2018-10-17 EC(2)caren-CLEAN.doc Supporting Statement Part A	IC Document

IC Title:

Field Test of Low Literacy Version of CAHPS Clinician and Group Survey

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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1	CG-CAHPS EZ /CG-CAHPS - English	Attachment A_Updated_06172019.pdf		No		Paper Only
Form and Instruction	2	CG-CAHPS EZ /CG-CAHPS - Spanish	Attachment B.pdf		No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 800

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	800	800
Annual IC Time Burden (Hours)	92	92
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Cover Letter	OMB Cover Letter.docx.doc	03/25/2019
Supporting Statement Part B	Attachment B.pdf	03/25/2019
Supporting Statement Part A	CAHPS EZ OMB Statement A 2018-10-17 EC(2)caren-CLEAN.doc	03/25/2019

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