Information Collection

Implementation of an Electronic Care Plan for People with Multiple Chronic Conditions

IC 241846 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⚠️ Notice: This information collection may be referencing outdated material.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 Implementation of an Electronic Care Plan for People with Multiple Chronic Conditions	Form and Instruction
1 Attachment A - Healthcare Staff Interview Guide (for pro Attachment A - Healthcare Staff Interview Guide (for providers & non-providers)_051420.docx	Form and Instruction
2 Attachment B - Health Information Technology Professiona Attachment B - Health Information Technology Professional Interview Guide_051420.docx	Form and Instruction
3 Attachment C - Patient Interview Guide Attachment C - Patient Interview Guide_051420.docx	Form and Instruction
OMB Supporting Statement_E-Care_051420.docx Supporting Statement	IC Document
OMB Cover Letter.docx Cover Letter	IC Document

IC Title:

Implementation of an Electronic Care Plan for People with Multiple Chronic Conditions

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?	Electronic Capability
Form and Instruction	1	Attachment A - Healthcare Staff Interview Guide (for providers & non-providers)	Attachment A - Healthcare Staff Interview Guide (for providers & non-providers)_051420.docx	No	Paper Only
Form and Instruction	2	Attachment B - Health Information Technology Professional Interview Guide	Attachment B - Health Information Technology Professional Interview Guide_051420.docx	No	Paper Only
Form and Instruction	3	Attachment C - Patient Interview Guide	Attachment C - Patient Interview Guide_051420.docx	No	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 34

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

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	34	34
Annual IC Time Burden (Hours)	34	34
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Supporting Statement	OMB Supporting Statement_E-Care_051420.docx	05/15/2020
Cover Letter	OMB Cover Letter.docx	05/15/2020

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