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⚠️ Notice: This information collection may be referencing outdated material.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

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

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.