Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 1 Survey Instrument – QI Software Users	Form	New	Repair queued
Form 2 Web Screener Survey	Form and Instruction	New	Repair queued
Form 1 Usability Script	Form and Instruction	New	Repair queued
Form 2 Proposed Approach for Task 7	Form and Instruction	New	Repair queued
Form 1 Proposed Approach for Task 3	Form and Instruction	New	Repair queued
Form 1 Appendix A: Interview Protocol	Form and Instruction	New	Repair queued
Form 1 Appendix A	Form and Instruction	New	Repair queued
Form 1 PCLC Survey	Form and Instruction	New	Repair queued
Form 4a Appendix D_Post-test Interview Protocol final 6 17 21	Form and Instruction	New	Repair queued
Form 3a Appendix C_Pre-test Interview Protocol_final_ 6 17 21	Form and Instruction	New	Repair queued
Form 1a Appendix A_Respondent Characteristics_final_6 17 21	Form and Instruction	New	Repair queued
Form 4 Appendix D: Post-test Evaluation Interview Protocol	Form and Instruction	New	Repair queued
Form 3 Appendix C: Pre-Test Interview Protocol	Form and Instruction	New	Repair queued
Form 2 Appendix B: Safety Attitude Survey	Form and Instruction	New	Repair queued
Form 1 Appendix A: Individual Respondent Characteristics Survey	Form and Instruction	New	Repair queued
Form 1 Appendix A	Form and Instruction	New	Repair queued
Form 3 Appendix D: Post-test Evaluation Interview Protocol	Form and Instruction	New	Repair queued
Form 3 Appendix C: Pre-Test Interview Protocol	Form and Instruction	New	Repair queued
Form 2 Appendix B: Organizational Readiness for Implementation Change (ORIC)	Form and Instruction	New	Repair queued
Form 1 Appendix A: Organizational Characteristics Survey	Form and Instruction	New	Repair queued
Form 1 AHRQ Data Tools Interview Guide	Form and Instruction	New	Available
Form 12 Appendix L: Training Observation Tool	Form and Instruction	New	Available
Form 11 Appendix K: Pilot Test Evaluation Protocol for Administrators – No TeamSTEPPS®	Form and Instruction	New	Available
Form 10 Appendix J: Pilot Test Evaluation Protocol for Administrators – TeamSTEPPS®	Form and Instruction	New	Available
Form 9 Appendix I: Pilot Test Evaluation Protocol for Staff – No TeamSTEPPS®	Form and Instruction	New	Available
Form 8 Appendix H: Pilot Test Evaluation Protocol for Staff – TeamSTEPPS®	Form and Instruction	New	Available
Form 7 Appendix G: Pilot Test Interview Protocol for Providers – No TeamSTEPPS®	Form and Instruction	New	Available
Form 6 Appendix F: Pilot Test Interview Protocol for Providers – TeamSTEPPS®	Form and Instruction	New	Available
Form 5 Appendix E: Organizational Readiness for Implementation Change (ORIC)	Form and Instruction	New	Available
Form 4 Appendix D: Individual Respondent Characteristics (Admin)	Form and Instruction	New	Available
Form 3 Appendix C: Individual Respondent Characteristics (Staff)	Form and Instruction	New	Available
Form 2 Appendix B: Individual Respondent Characteristics (Providers)	Form	New	Available
Form 1 Appendix A: Setting Demographics Survey	Form and Instruction	New	Repair queued
Form 1 Nominator/Partner Survey	Form and Instruction	Unchanged	Available
Form 7 Appendix	Form and Instruction	Unchanged	Available
Form 6 Appendix F	Form and Instruction	Unchanged	Available
Form 5 Appendix E	Form and Instruction	Unchanged	Available
Form 4 Appendix D	Form and Instruction	Unchanged	Available
Form 3 Appendix C	Form and Instruction	Unchanged	Available
Form 2 Appendix B	Form and Instruction	Unchanged	Available
Form 1 Appendix A	Form and Instruction	Unchanged	Repair queued
Form 1 Card Sort B: Online Data Collection for AHRQ.gov	Form and Instruction	Unchanged	Repair queued
Form 1 Card Sort A: Online Data Collection for AHRQ.gov	Form and Instruction	Unchanged	Available
Form 4 Post Website Evaluation	Form and Instruction	Unchanged	Available
Form 3 End user Survey to support redesign of the NCEPCR website: Primary Care Researchers	Form and Instruction	Unchanged	Available
Form 2 End user Survey to support redesign of the NCEPCR website: Primary Care clinicians/Quality Improvement Leaders	Form and Instruction	Unchanged	Available
Form 1 End user Survey to support redesign of the NCEPCR website: Primary Care clinicians/Quality Improvement Leaders	Form and Instruction	Unchanged	Available
Form 1 Nominator/Partner Survey	Form and Instruction	Unchanged	Available
Form 2 HSPCR Interview Guide: Researchers in HSR and PCR	Form and Instruction	Unchanged	Available
Form 1 HSPCR Interview Guide: Other Stakeholders in HSR and PCR	Form and Instruction	Unchanged	Available
Form 1 INTERVIEW DISCUSSION GUIDES	Form and Instruction	Unchanged	Available
Form 1 Web-based Survey	Form and Instruction	Unchanged	Repair queued
Form 1 System Usability Scale (SUS)	Form and Instruction	Unchanged	Available
Form 1 Health Information Technology Professional Interview Guide	Form and Instruction	Unchanged	Available
Form 1 Provider Interview Guide	Form and Instruction	Unchanged	Available
Form 1 Patient Interview Guide	Form and Instruction	Unchanged	Available
Form 1 Readiness for Change Assessment	Form and Instruction	Unchanged	Available
Form 1 Request for Opioid Project Information	Form and Instruction	Unchanged	Available
Form 1 2018 AHRQ QI SURVEY	Form and Instruction	Unchanged	Available
Form 2 Questions for Users of CAHPS Technical Assistance	Form and Instruction	Unchanged	Repair queued
Form 1 Questions for Users of SOPS Technical Assistance	Form and Instruction	Unchanged	Available
Form 5 Category 5	Form and Instruction	Unchanged	Available
Form 4 Category 4	Form and Instruction	Unchanged	Available
Form 3 Category 3	Form and Instruction	Unchanged	Available
Form 2 Category 2	Form and Instruction	Unchanged	Available
Form 1 Category 1	Form and Instruction	Unchanged	Available
Form 1 Stakeholders	Form and Instruction	Unchanged	Available
Form 1 Patient Key Informants	Form and Instruction	Unchanged	Available
Form 1 Nominator Customer Satisfaction Survey	Form and Instruction	Unchanged	Available
Form 1 Attachment A—AHRQ National Healthcare Quality and Disparities Reports (QDR) and National Quality Strategy (NQS) Customer Satisfaction Interview Guide	Form and Instruction	Unchanged	Available
Form 1 Questions for Stakeholders	Form and Instruction	Unchanged	Available
Form 1 Questions for Patient Key Informants	Form and Instruction	Unchanged	Available
Form 1 Nominator Customer Satisfaction Survey	Form and Instruction	Unchanged	Available
Form 2 2. Appendix B – Moderator Guide	Form and Instruction	Unchanged	Available
Form 2 MONAHRQ Professional End Users Focus Group protocol	Form and Instruction	Unchanged	Repair queued
Form 1 AHRQ.gov Taxonomy Tree Test	Form and Instruction	Unchanged	Available
Supporting Statement Part A -- 09152020.docx	Supporting Statement A	Uploaded 2020-09-14	Available
Generic Clearance Submission Template.doc	Supplementary Document	Uploaded 2011-06-28	Available
Supporting Statement Part B -- Generic Clearance.docx	Supporting Statement B	Uploaded 2020-09-14	Available
Attachment A -- Healthcare Research and Quality Act of 1999.pdf	Supplementary Document	Uploaded 2011-04-26	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
259196	QI Program User Survey	Form	New	Survey Instrument – QI Software Users
252763	Voluntary Customer Satisfaction Survey of AHRQ PSNet Users	Form and Instruction	New	Web Screener Survey
252763	Voluntary Customer Satisfaction Survey of AHRQ PSNet Users	Form and Instruction	New	Usability Script
251010	TA User Feedback for Program and User Support and Quality Measure Tool Development for CAHPS® and SOPS	Form and Instruction	New	Proposed Approach for Task 7
251010	TA User Feedback for Program and User Support and Quality Measure Tool Development for CAHPS® and SOPS	Form and Instruction	New	Proposed Approach for Task 3
251001	The AHRQ Safety Program for Improving Surgical Care and Recovery (ISCR) Qualitative Evaluation	Form and Instruction	New	Appendix A: Interview Protocol
250572	Administration of "Use of Agency for Healthcare Research and Quality (AHRQ) Tools to Measure Aspects of Patient Safety" Questionnaire to AHRQ SOPS® Listserv Subscribers	Form and Instruction	New	Appendix A
250572	Administration of "Use of Agency for Healthcare Research and Quality (AHRQ) Tools to Measure Aspects of Patient Safety" Questionnaire to AHRQ SOPS® Listserv Subscribers	Other-Instrument	New
250559	Agency for Healthcare Research and Quality (AHRQ) COVID-19 Primary Care Learning Community Participant Survey	Form and Instruction	New	PCLC Survey
247238	Building Diagnostic Safety Capacity - Diagnostic Calibration Resource Evaluation Plan	Form and Instruction	New	Appendix D_Post-test Interview Protocol final 6 17 21
247238	Building Diagnostic Safety Capacity - Diagnostic Calibration Resource Evaluation Plan	Form and Instruction	New	Appendix C_Pre-test Interview Protocol_final_ 6 17 21
247238	Building Diagnostic Safety Capacity - Diagnostic Calibration Resource Evaluation Plan	Form and Instruction	New	Appendix A_Respondent Characteristics_final_6 17 21
247238	Building Diagnostic Safety Capacity - Diagnostic Calibration Resource Evaluation Plan	Form and Instruction	New	Appendix D: Post-test Evaluation Interview Protocol
247238	Building Diagnostic Safety Capacity - Diagnostic Calibration Resource Evaluation Plan	Form and Instruction	New	Appendix C: Pre-Test Interview Protocol
247238	Building Diagnostic Safety Capacity - Diagnostic Calibration Resource Evaluation Plan	Form and Instruction	New	Appendix B: Safety Attitude Survey
247238	Building Diagnostic Safety Capacity - Diagnostic Calibration Resource Evaluation Plan	Form and Instruction	New	Appendix A: Individual Respondent Characteristics Survey
246687	ECHO National Nursing Home COVID-19 Action Network Customer Satisfaction Survey	Form and Instruction	New	Appendix A
245332	Building Diagnostic Safety Capacity - Diagnostic Safety Measurement Resource Evaluation Plan	Form and Instruction	New	Appendix D: Post-test Evaluation Interview Protocol
245332	Building Diagnostic Safety Capacity - Diagnostic Safety Measurement Resource Evaluation Plan	Form and Instruction	New	Appendix C: Pre-Test Interview Protocol
245332	Building Diagnostic Safety Capacity - Diagnostic Safety Measurement Resource Evaluation Plan	Form and Instruction	New	Appendix B: Organizational Readiness for Implementation Change (ORIC)
245332	Building Diagnostic Safety Capacity - Diagnostic Safety Measurement Resource Evaluation Plan	Form and Instruction	New	Appendix A: Organizational Characteristics Survey
244395	Information Gathering and Usability Testing for AHRQ Data Tools Platform Development and Maintenance	Form and Instruction	New	AHRQ Data Tools Interview Guide
244358	Building Diagnostic Safety Capacity – TeamSTEPPS® Course Evaluation	Form and Instruction	New	Appendix L: Training Observation Tool
244358	Building Diagnostic Safety Capacity – TeamSTEPPS® Course Evaluation	Form and Instruction	New	Appendix K: Pilot Test Evaluation Protocol for Administrators – No TeamSTEPPS®
244358	Building Diagnostic Safety Capacity – TeamSTEPPS® Course Evaluation	Form and Instruction	New	Appendix J: Pilot Test Evaluation Protocol for Administrators – TeamSTEPPS®
244358	Building Diagnostic Safety Capacity – TeamSTEPPS® Course Evaluation	Form and Instruction	New	Appendix I: Pilot Test Evaluation Protocol for Staff – No TeamSTEPPS®
244358	Building Diagnostic Safety Capacity – TeamSTEPPS® Course Evaluation	Form and Instruction	New	Appendix H: Pilot Test Evaluation Protocol for Staff – TeamSTEPPS®
244358	Building Diagnostic Safety Capacity – TeamSTEPPS® Course Evaluation	Form and Instruction	New	Appendix G: Pilot Test Interview Protocol for Providers – No TeamSTEPPS®
244358	Building Diagnostic Safety Capacity – TeamSTEPPS® Course Evaluation	Form and Instruction	New	Appendix F: Pilot Test Interview Protocol for Providers – TeamSTEPPS®
244358	Building Diagnostic Safety Capacity – TeamSTEPPS® Course Evaluation	Form and Instruction	New	Appendix E: Organizational Readiness for Implementation Change (ORIC)
244358	Building Diagnostic Safety Capacity – TeamSTEPPS® Course Evaluation	Form and Instruction	New	Appendix D: Individual Respondent Characteristics (Admin)
244358	Building Diagnostic Safety Capacity – TeamSTEPPS® Course Evaluation	Form and Instruction	New	Appendix C: Individual Respondent Characteristics (Staff)
244358	Building Diagnostic Safety Capacity – TeamSTEPPS® Course Evaluation	Form	New	Appendix B: Individual Respondent Characteristics (Providers)
244358	Building Diagnostic Safety Capacity – TeamSTEPPS® Course Evaluation	Form and Instruction	New	Appendix A: Setting Demographics Survey
242601	Partner/Nominator Customer Satisfaction Survey for the Evidence Based Practice Center (EPC) Division	Form and Instruction	Unchanged	Nominator/Partner Survey
241698	Stakeholder Interviews for Task 4 of AHRQ's ACTION III Diagnostic Safety Capacity Building Contract	Form and Instruction	Unchanged	Appendix
241698	Stakeholder Interviews for Task 4 of AHRQ's ACTION III Diagnostic Safety Capacity Building Contract	Form and Instruction	Unchanged	Appendix F
241698	Stakeholder Interviews for Task 4 of AHRQ's ACTION III Diagnostic Safety Capacity Building Contract	Form and Instruction	Unchanged	Appendix E
241698	Stakeholder Interviews for Task 4 of AHRQ's ACTION III Diagnostic Safety Capacity Building Contract	Form and Instruction	Unchanged	Appendix D
241698	Stakeholder Interviews for Task 4 of AHRQ's ACTION III Diagnostic Safety Capacity Building Contract	Form and Instruction	Unchanged	Appendix C
241698	Stakeholder Interviews for Task 4 of AHRQ's ACTION III Diagnostic Safety Capacity Building Contract	Form and Instruction	Unchanged	Appendix B
241698	Stakeholder Interviews for Task 4 of AHRQ's ACTION III Diagnostic Safety Capacity Building Contract	Form and Instruction	Unchanged	Appendix A
241678	Card Sort B: Online Data Collection for AHRQ.gov	Form and Instruction	Unchanged	Card Sort B: Online Data Collection for AHRQ.gov
241677	Card Sort A: Online Data Collection for AHRQ.gov	Form and Instruction	Unchanged	Card Sort A: Online Data Collection for AHRQ.gov
240821	End user Survey to support redesign of the National Center for Excellence in Primary Care Research website	Form and Instruction	Unchanged	Post Website Evaluation
240821	End user Survey to support redesign of the National Center for Excellence in Primary Care Research website	Form and Instruction	Unchanged	End user Survey to support redesign of the NCEPCR website: Primary Care Researchers
240821	End user Survey to support redesign of the National Center for Excellence in Primary Care Research website	Form and Instruction	Unchanged	End user Survey to support redesign of the NCEPCR website: Primary Care clinicians/Quality Improvement Leaders
240821	End user Survey to support redesign of the National Center for Excellence in Primary Care Research website	Form and Instruction	Unchanged	End user Survey to support redesign of the NCEPCR website: Primary Care clinicians/Quality Improvement Leaders
235082	Partner/Nominator Customer Satisfaction Survey for the Evidence Based Practice Center (EPC) Division	Form and Instruction	Unchanged	Nominator/Partner Survey
234568	Health Services and Primary Care Research (HSPCR) Study, Stakeholder Interviews	Form and Instruction	Unchanged	HSPCR Interview Guide: Researchers in HSR and PCR
234568	Health Services and Primary Care Research (HSPCR) Study, Stakeholder Interviews	Form and Instruction	Unchanged	HSPCR Interview Guide: Other Stakeholders in HSR and PCR
234196	Information Gathering and Usability Testing to Harmonize AHRQ Data Tools	Form and Instruction	Unchanged	INTERVIEW DISCUSSION GUIDES
233835	Agency for Healthcare Research and Quality (AHRQ) Quality Indicators (QI) Customer Survey	Form and Instruction	Unchanged	Web-based Survey
233778	System Usability Scale (SUS)	Form and Instruction	Unchanged	System Usability Scale (SUS)
233777	Health Information Technology Professional Interview Guide	Form and Instruction	Unchanged	Health Information Technology Professional Interview Guide
233776	Provider Interview Guide	Form and Instruction	Unchanged	Provider Interview Guide
233775	Patient Interview Guide	Form and Instruction	Unchanged	Patient Interview Guide
233758	Readiness for Change Assessment	Form and Instruction	Unchanged	Readiness for Change Assessment
232977	Request for Opioid Project Information from Patient Safety Organizations (PSOs)	Form and Instruction	Unchanged	Request for Opioid Project Information
231422	Agency for Healthcare Research and Quality (AHRQ) Quality Indicators (QI) Customer Survey	Form and Instruction	Unchanged	2018 AHRQ QI SURVEY
231329	Technical Assistance (TA) User Feedback for Program and User Support and Quality Measure Tool Development for Consumer Assessment of Healthcare Providers and Systems (CAHPS) and Surveys on Patient Sa	Form and Instruction	Unchanged	Questions for Users of CAHPS Technical Assistance
231329	Technical Assistance (TA) User Feedback for Program and User Support and Quality Measure Tool Development for Consumer Assessment of Healthcare Providers and Systems (CAHPS) and Surveys on Patient Sa	Form and Instruction	Unchanged	Questions for Users of SOPS Technical Assistance
229442	Stakeholder Interviews for Task 1 of AHRQ's SPPC-II Contract (RFTOP #17-233-SOL-00520)	Form and Instruction	Unchanged	Category 5
229442	Stakeholder Interviews for Task 1 of AHRQ's SPPC-II Contract (RFTOP #17-233-SOL-00520)	Form and Instruction	Unchanged	Category 4
229442	Stakeholder Interviews for Task 1 of AHRQ's SPPC-II Contract (RFTOP #17-233-SOL-00520)	Form and Instruction	Unchanged	Category 3
229442	Stakeholder Interviews for Task 1 of AHRQ's SPPC-II Contract (RFTOP #17-233-SOL-00520)	Form and Instruction	Unchanged	Category 2
229442	Stakeholder Interviews for Task 1 of AHRQ's SPPC-II Contract (RFTOP #17-233-SOL-00520)	Form and Instruction	Unchanged	Category 1
228950	Stakeholder Customer Satisfaction Survey for the Evidence Based Practice Center (EPC) Program	Form and Instruction	Unchanged	Stakeholders
228948	Patient Key Informant Customer Satisfaction Survey for the Evidence Based Practice Center (EPC) Division	Form and Instruction	Unchanged	Patient Key Informants
228946	Nominator Customer Satisfaction Survey for the Evidence Based Practice Center (EPC) Division	Form and Instruction	Unchanged	Nominator Customer Satisfaction Survey
225165	Customer Satisfaction Analysis for the AHRQ National Healthcare Quality and Disparities Report and National Quality Strategy Products and Websites	Form and Instruction	Unchanged	Attachment A—AHRQ National Healthcare Quality and Disparities Reports (QDR) and National Quality Strategy (NQS) Customer Satisfaction Interview Guide
223278	Stakeholder Customer Satisfaction Survey for the Evidence Based Practice Center (EPC) Program	Form and Instruction	Unchanged	Questions for Stakeholders
223277	Patient Key Informant Customer Satisfaction Survey for the Evidence Based Practice Center (EPC) Division	Form and Instruction	Unchanged	Questions for Patient Key Informants
223276	Nominator Customer Satisfaction Survey for the Evidence Based Practice Center (EPC) Division	Form and Instruction	Unchanged	Nominator Customer Satisfaction Survey
222551	Focus Groups on TeamSTEPPS® for Long-Term Care Curriculum	Form and Instruction	Unchanged	2. Appendix B – Moderator Guide
222551	Focus Groups on TeamSTEPPS® for Long-Term Care Curriculum	Other-screener	Unchanged
215883	MONAHRQ Program Evaluation End User Focus Groups Protocol	Form and Instruction	Unchanged	MONAHRQ Professional End Users Focus Group protocol
215883	MONAHRQ Program Evaluation End User Focus Groups Protocol	Instruction	Unchanged
214535	AHRQ.gov Taxonomy Tree Test	Form and Instruction	Unchanged	AHRQ.gov Taxonomy Tree Test

ICR Details

OMB Control No: 0935-0179	ICR Reference No: 202009-0935-002
Status: Historical Active	Previous ICR Reference No: 201709-0935-001
Agency/Subagency: HHS/AHRQ	Agency Tracking No:
Title: Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 11/02/2020
Retrieve Notice of Action (NOA)	Date Received in OIRA: 09/21/2020
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2023	36 Months From Approved	11/30/2020
Responses	10,900	0	10,900
Time Burden (Hours)	3,383	0	3,383
Cost Burden (Dollars)	0	0	0

---

Abstract: This collection of information is necessary to enable the Agency to garner customer and stakeholder feedback in an efficient, timely manner, in accordance with our commitment to improving service delivery. The information collected from our customers and stakeholders will help ensure that users have an effective, efficient, and satisfying experience with the Agency's programs.

---

Authorizing Statute(s): US Code: 42 USC 299 Name of Law: Healthcare Research and Quality Act of 1999
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 35654	06/11/2020
30-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 58061	09/17/2020
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 39

table that charts list of burden

IC Title	Form No.	Form Name
AHRQ.gov Taxonomy Tree Test	1	AHRQ.gov Taxonomy Tree Test
Administration of "Use of Agency for Healthcare Research and Quality (AHRQ) Tools to Measure Aspects of Patient Safety" Questionnaire to AHRQ SOPS® Listserv Subscribers	1	Appendix A
Agency for Healthcare Research and Quality (AHRQ) COVID-19 Primary Care Learning Community Participant Survey	1	PCLC Survey
Agency for Healthcare Research and Quality (AHRQ) Quality Indicators (QI) Customer Survey	1	2018 AHRQ QI SURVEY
Agency for Healthcare Research and Quality (AHRQ) Quality Indicators (QI) Customer Survey	1	Web-based Survey
Building Diagnostic Safety Capacity - Diagnostic Calibration Resource Evaluation Plan	1a, 3a, 4a, 1, 2, 3, 4	Appendix A: Individual Respondent Characteristics Survey ,   Appendix B: Safety Attitude Survey ,   Appendix C: Pre-Test Interview Protocol ,   Appendix D: Post-test Evaluation Interview Protocol ,   Appendix A_Respondent Characteristics_final_6 17 21 ,   Appendix C_Pre-test Interview Protocol_final_ 6 17 21 ,   Appendix D_Post-test Interview Protocol final 6 17 21
Building Diagnostic Safety Capacity - Diagnostic Safety Measurement Resource Evaluation Plan	2, 3, 1, 3	Appendix A: Organizational Characteristics Survey ,   Appendix B: Organizational Readiness for Implementation Change (ORIC) ,   Appendix C: Pre-Test Interview Protocol ,   Appendix D: Post-test Evaluation Interview Protocol
Building Diagnostic Safety Capacity – TeamSTEPPS® Course Evaluation	4, 1, 2, 3, 5, 6, 7, 8, 9, 10, 11, 12	Appendix A: Setting Demographics Survey ,   Appendix B: Individual Respondent Characteristics (Providers) ,   Appendix C: Individual Respondent Characteristics (Staff) ,   Appendix D: Individual Respondent Characteristics (Admin) ,   Appendix E: Organizational Readiness for Implementation Change (ORIC) ,   Appendix F: Pilot Test Interview Protocol for Providers – TeamSTEPPS® ,   Appendix G: Pilot Test Interview Protocol for Providers – No TeamSTEPPS® ,   Appendix H: Pilot Test Evaluation Protocol for Staff – TeamSTEPPS® ,   Appendix I: Pilot Test Evaluation Protocol for Staff – No TeamSTEPPS® ,   Appendix J: Pilot Test Evaluation Protocol for Administrators – TeamSTEPPS® ,   Appendix K: Pilot Test Evaluation Protocol for Administrators – No TeamSTEPPS® ,   Appendix L: Training Observation Tool
Card Sort A: Online Data Collection for AHRQ.gov	1	Card Sort A: Online Data Collection for AHRQ.gov
Card Sort B: Online Data Collection for AHRQ.gov	1	Card Sort B: Online Data Collection for AHRQ.gov
Customer Satisfaction Analysis for the AHRQ National Healthcare Quality and Disparities Report and National Quality Strategy Products and Websites	1	Attachment A—AHRQ National Healthcare Quality and Disparities Reports (QDR) and National Quality Strategy (NQS) Customer Satisfaction Interview Guide
ECHO National Nursing Home COVID-19 Action Network Customer Satisfaction Survey	1	Appendix A
End user Survey to support redesign of the National Center for Excellence in Primary Care Research website	1, 2, 3, 4	End user Survey to support redesign of the NCEPCR website: Primary Care clinicians/Quality Improvement Leaders ,   End user Survey to support redesign of the NCEPCR website: Primary Care clinicians/Quality Improvement Leaders ,   End user Survey to support redesign of the NCEPCR website: Primary Care Researchers ,   Post Website Evaluation
Focus Groups on TeamSTEPPS® for Long-Term Care Curriculum	2	2. Appendix B – Moderator Guide
Health Information Technology Professional Interview Guide	1	Health Information Technology Professional Interview Guide
Health Services and Primary Care Research (HSPCR) Study, Stakeholder Interviews	2, 1	HSPCR Interview Guide: Other Stakeholders in HSR and PCR ,   HSPCR Interview Guide: Researchers in HSR and PCR
Information Gathering and Usability Testing for AHRQ Data Tools Platform Development and Maintenance	1	AHRQ Data Tools Interview Guide
Information Gathering and Usability Testing to Harmonize AHRQ Data Tools	1	INTERVIEW DISCUSSION GUIDES
MONAHRQ Program Evaluation End User Focus Groups Protocol	2	MONAHRQ Professional End Users Focus Group protocol
Nominator Customer Satisfaction Survey for the Evidence Based Practice Center (EPC) Division	1	Nominator Customer Satisfaction Survey
Nominator Customer Satisfaction Survey for the Evidence Based Practice Center (EPC) Division	1	Nominator Customer Satisfaction Survey
Partner/Nominator Customer Satisfaction Survey for the Evidence Based Practice Center (EPC) Division	1	Nominator/Partner Survey
Partner/Nominator Customer Satisfaction Survey for the Evidence Based Practice Center (EPC) Division	1	Nominator/Partner Survey
Patient Interview Guide	1	Patient Interview Guide
Patient Key Informant Customer Satisfaction Survey for the Evidence Based Practice Center (EPC) Division	1	Patient Key Informants
Patient Key Informant Customer Satisfaction Survey for the Evidence Based Practice Center (EPC) Division	1	Questions for Patient Key Informants
Provider Interview Guide	1	Provider Interview Guide
QI Program User Survey	1	Survey Instrument – QI Software Users
Readiness for Change Assessment	1	Readiness for Change Assessment
Request for Opioid Project Information from Patient Safety Organizations (PSOs)	1	Request for Opioid Project Information
Stakeholder Customer Satisfaction Survey for the Evidence Based Practice Center (EPC) Program	1	Questions for Stakeholders
Stakeholder Customer Satisfaction Survey for the Evidence Based Practice Center (EPC) Program	1	Stakeholders
Stakeholder Interviews for Task 1 of AHRQ's SPPC-II Contract (RFTOP #17-233-SOL-00520)	2, 5, 1, 3, 4	Category 1 ,   Category 2 ,   Category 3 ,   Category 4 ,   Category 5
Stakeholder Interviews for Task 4 of AHRQ's ACTION III Diagnostic Safety Capacity Building Contract	1, 2, 3, 4, 5, 6, 7	Appendix A ,   Appendix B ,   Appendix C ,   Appendix D ,   Appendix E ,   Appendix F ,   Appendix
System Usability Scale (SUS)	1	System Usability Scale (SUS)
TA User Feedback for Program and User Support and Quality Measure Tool Development for CAHPS® and SOPS	1, 2	Proposed Approach for Task 3 ,   Proposed Approach for Task 7
Technical Assistance (TA) User Feedback for Program and User Support and Quality Measure Tool Development for Consumer Assessment of Healthcare Providers and Systems (CAHPS) and Surveys on Patient Sa	2, 1	Questions for Users of SOPS Technical Assistance ,   Questions for Users of CAHPS Technical Assistance
The AHRQ Safety Program for Improving Surgical Care and Recovery (ISCR) Qualitative Evaluation	1	Appendix A: Interview Protocol
Voluntary Customer Satisfaction Survey of AHRQ PSNet Users	1, 2	Usability Script ,   Web Screener Survey

---

ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	10,900	10,900	0	0	0	0
Annual Time Burden (Hours)	3,383	3,383	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

---

Annual Cost to Federal Government: $848,556

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

---

Common Form ICR:  No

---

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 09/21/2020

---