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

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⚠️ Notice: This information collection may be referencing outdated material.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

Information Collection (IC) Details

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:

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 – 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 – 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 %

	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

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 – Field Test Oral Consent Form – Tier 1	Attachment C - Field Test OralConsent-JHU SOM_Tier I.docx	03/29/2019
Attachment D – Field Test Oral Consent Form – Tier 2	Attachment D - Field Test OralConsent-JHU SOM_Tier II.docx	03/29/2019
Attachment F – 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.