Information Collection

EHR data (Cohorts 1, 2, and 3)

IC 227723 under ICR 201906-0935-002 · OMB 0935-0238.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Attachment L Clinical measure instructions.1.docx	Instruction
Att K Clinical measure template and data dictionary.pdf Attachment K: Clinical measures template for EHR data extracts	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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
Instruction			Attachment L Clinical measure instructions.1.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 334

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

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

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	4,008	4,008
Annual IC Time Burden (Hours)	4,008	4,008
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment K: Clinical measures template for EHR data extracts	Att K Clinical measure template and data dictionary.pdf	07/26/2017

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