Information Collection

Field Test of SPPC-II Toolkit and Training Modules during Pilot Phase of SPPC-II Demonstration Project

IC 235532 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⚠️ Notice: This information collection may be referencing outdated material.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 Field Test of SPPC-II Toolkit and Training Modules during Pilot Phase of SPPC-II Demonstration Project	Form and Instruction
1 Attachment B – Field Test Interview Guides Attachment B - Field Test Interview Guides_version - 4.1.19 with OMB boxes.docx	Form and Instruction
2 Attachment E – SPPC-II Field Test - Short Questionnaire Attachment E- SPPC-II short questionnaire v4.docx	Form and Instruction
1 Attachment B- Field Test Interview Guides Final Attachment B - Field Test Interview Guides_version - 5.23.19 - clean.docx	Form and Instruction
2 Attachment E SPPC II Short Questionnaire Final Attachment E- SPPC-II short questionnaire v4 - 5.23.19 - clean.docx	Form and Instruction
Attachment A - HRQA 1999- AHRQ Authorizing Legislation.pdf Attachment A -- Healthcare Research and Quality Act of 1999	IC Document
Attachment C - Field Test OralConsent-JHU SOM_Tier I.docx Attachment C – Field Test Oral Consent Form – Tier 1	IC Document
Attachment D - Field Test OralConsent-JHU SOM_Tier II.docx Attachment D – Field Test Oral Consent Form – Tier 2	IC Document
Attachment F List of Stakeholder Panel Members.docx Attachment F – List of Stakeholder Panel Members	IC Document
OMB Cover Letter-3.31.docx (003).doc Cover Letter	IC Document
Supporting Statement Part A -Pretesting Clearance 2017 - SPPCII Field Test eb.doc Supporting Statement Part A	IC Document

IC Title:

Field Test of SPPC-II Toolkit and Training Modules during Pilot Phase of SPPC-II Demonstration Project

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	Attachment E SPPC II Short Questionnaire Final	Attachment E- SPPC-II short questionnaire v4 - 5.23.19 - clean.docx	Yes	Yes	Fillable Fileable
Form and Instruction	1	Attachment B- Field Test Interview Guides Final	Attachment B - Field Test Interview Guides_version - 5.23.19 - clean.docx	Yes	Yes	Fillable Fileable
Form and Instruction	1	Attachment B â Field Test Interview Guides	Attachment B - Field Test Interview Guides_version - 4.1.19 with OMB boxes.docx	Yes	Yes	Fillable Fileable
Form and Instruction	2	Attachment E â SPPC-II Field Test - Short Questionnaire	Attachment E- SPPC-II short questionnaire v4.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 32

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	32	32
Annual IC Time Burden (Hours)	17	17
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment A -- Healthcare Research and Quality Act of 1999	Attachment A - HRQA 1999- AHRQ Authorizing Legislation.pdf	03/29/2019
Attachment C â Field Test Oral Consent Form â Tier 1	Attachment C - Field Test OralConsent-JHU SOM_Tier I.docx	03/29/2019
Attachment D â Field Test Oral Consent Form â Tier 2	Attachment D - Field Test OralConsent-JHU SOM_Tier II.docx	03/29/2019
Attachment F â List of Stakeholder Panel Members	Attachment F List of Stakeholder Panel Members.docx	03/29/2019
Cover Letter	OMB Cover Letter-3.31.docx (003).doc	04/02/2019
Supporting Statement Part A	Supporting Statement Part A -Pretesting Clearance 2017 - SPPCII Field Test eb.doc	03/29/2019

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