Questionnaire and Data Collection Testing, Evaluation, and Research for the Agency for Healthcare Research and Quality

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Attachment 5- Pre R1 Questionnaire	Form and Instruction	New	Repair queued
Attachment 7 Round 1 Re-Enumeration	Form and Instruction	New	Repair queued
Attachment 6 - Round 1 Enumeration	Form and Instruction	New	Repair queued
Form 4 Attachment 4- Generic claims authorization script	Form and Instruction	New	Repair queued
Form 3 Attachment 3- Blue Button Access Authorization Script	Form and Instruction	New	Repair queued
Form 2 Attachment 2- Cognitive Testing Materials for Health Care Entry	Form and Instruction	New	Repair queued
Form 1 Attachment 1- Cognitive Testing Materials for Pre- R1	Form and Instruction	New	Repair queued
Form 1 Attachment 1- Exit Panel CMS Administrative Data Access Authorization	Form and Instruction	New	Repair queued
Form 1, 2 MO Survey Version 2.0 and Workplace Safety Supplemental Items Cognitive Interview Guide - REVISED	Form and Instruction	New	Repair queued
Form 4 Attachment B - Medical Office Data Use Agreement (DUA) - REVISED	Form and Instruction	New	Repair queued
Form 6 Pretest of SOPS Medical Office Survey 2.0 and Workplace Safety Supplemental Items - REVISED	Form and Instruction	New	Repair queued
Form 5 Medical Office Background Information Form	Form and Instruction	New	Repair queued
Form 3 Medical Office Point of Contact (POC) Instructions	Form and Instruction	New	Repair queued
Form 1 SOPS Nursing Home Survey with Workplace Safety Supplemental Item Set	Form and Instruction	New	Repair queued
Form 1 Provider Focus Group	Form and Instruction	Unchanged	Available
Form 1 Provider Focus Group	Form and Instruction	Unchanged	Repair queued
Form 1 Provider and Patient Interview	Form and Instruction	Unchanged	Available
Form 1 Provider and Patient Interview	Form and Instruction	Unchanged	Repair queued
Form 1 Patient and Caregiver Usability Interview	Form and Instruction	Unchanged	Available
Form 1 Patient and Caregiver Usability Interview	Form and Instruction	Unchanged	Repair queued
Form 1 Patient and Caregiver Survey	Form and Instruction	Unchanged	Available
Form 1 Patient and Caregiver Survey	Form and Instruction	Unchanged	Repair queued
Form 1 Pilot Screener	Form and Instruction	Unchanged	Available
Form 1 MEPS Alternative Sampling Design Pilot Test	Form and Instruction	Unchanged	Repair queued
Form 2E Attachment 2-E. Study 2 MCI Protocol	Form and Instruction	Unchanged	Available
Form 2B Attachment 2-B. Study 2 Recruitment telephone script + scheduling MCI interview	Form and Instruction	Unchanged	Available
Form 1I Attachment 1-I. Study 1 MEPS Abbreviated R2 Interview	Form and Instruction	Unchanged	Available
Form 1H Attachment 1-H. Study 1 Protocol 3 (R2)	Form and Instruction	Unchanged	Available
Form 1G Attachment 1-G. Study 1 MCI Protocol 2	Form and Instruction	Unchanged	Available
Form 1F Attachment 1-F. Study 1 MCI Protocol 1	Form and Instruction	Unchanged	Available
Form 1C Attachment 1-B. Study 1 Recruitment screener	Form and Instruction	Unchanged	Available
Form 1B Attachment 1-B. Study 1 Recruitment screener	Form and Instruction	Unchanged	Available
Form 1B Feasibility Study for a MEPS Monthly Check-In	Form and Instruction	Unchanged	Repair queued
Form Attachment F Nursing Home Background Information Form	Form and Instruction	Unchanged	Available
Form 3 Attachment A: Draft Workplace Safety Supplemental Item Set	Form and Instruction	Unchanged	Available
Form 2 Attachment C: Nursing Home Point of Contact (POC) Instructions	Form and Instruction	Unchanged	Available
Form 1 Attachment B: Draft Workplace Safety Cognitive Interview Guide	Form and Instruction	Unchanged	Available
Form 1 Pilot Test of the Proposed Workplace Safety Supplemental Item Set For the AHRQ Surveys on Patient Safety Culture™ (SOPS®) Nursing Home Survey	Form and Instruction	Unchanged	Available
Form 1 Survey of End-of-Life Care	Form and Instruction	Unchanged	Available
Form 1 Field Test of A Survey of End-of-Life Care	Form and Instruction	Unchanged	Repair queued
Form 2 Pilot test – Plan Questionnaire	Form and Instruction	Unchanged	Available
Form 1 Pilot test – Establishment Questionnaire	Form and Instruction	Unchanged	Available
Form 1 Pilot Test of the Revised Data Collection Method for the Medical Expenditure Panel Survey - Insurance Component	Form and Instruction	Unchanged	Repair queued
Attachment D - Generic Clearance Submission.docx	Supplementary Document	Uploaded 2024-01-25	Repair queued
Attachment B - Data Collections under Generic 0935-0124.docx	Supplementary Document	Uploaded 2024-01-25	Repair queued
Attachment A - Healthcare Research and Quality Act of 1999.pdf	Supplementary Document	Uploaded 2024-01-25	Repair queued
Supporting Statement Part B - Generic 0935-0124 Questionnaire and Data Collection Testing, Evaluation and Research.docx	Supporting Statement B	Uploaded 2024-01-25	Repair queued
Supporting Statement Part A - Generic 0935-0124 Questionnaire and Data Collection Testing Evaluation and Research_012524.docx	Supporting Statement A	Uploaded 2024-01-25	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
282045	MEPS-HC Address-Based Sample (ABS) Field Test	Form and Instruction	New	Attachment 5- Pre R1 Questionnaire
282045	MEPS-HC Address-Based Sample (ABS) Field Test	Form and Instruction	New	Attachment 7 Round 1 Re-Enumeration
282045	MEPS-HC Address-Based Sample (ABS) Field Test	Form and Instruction	New	Attachment 6 - Round 1 Enumeration
280554	MEPS-HC Cognitive Testing	Form and Instruction	New	Attachment 4- Generic claims authorization script
280554	MEPS-HC Cognitive Testing	Form and Instruction	New	Attachment 3- Blue Button Access Authorization Script
280554	MEPS-HC Cognitive Testing	Form and Instruction	New	Attachment 2- Cognitive Testing Materials for Health Care Entry
280554	MEPS-HC Cognitive Testing	Form and Instruction	New	Attachment 1- Cognitive Testing Materials for Pre- R1
280496	MEPS-HC Exited Respondents Administrative Data Access	Form and Instruction	New	Attachment 1- Exit Panel CMS Administrative Data Access Authorization
276298	Pretest of the Proposed Revisions to the Medical Office Survey on Patient Safety Culture (MO SOPS) to Version 2.0, with New Workplace Safety Supplemental Items for Medical Offices	Form and Instruction	New	MO Survey Version 2.0 and Workplace Safety Supplemental Items Cognitive Interview Guide - REVISED
276298	Pretest of the Proposed Revisions to the Medical Office Survey on Patient Safety Culture (MO SOPS) to Version 2.0, with New Workplace Safety Supplemental Items for Medical Offices	Form and Instruction	New	Attachment B - Medical Office Data Use Agreement (DUA) - REVISED
276298	Pretest of the Proposed Revisions to the Medical Office Survey on Patient Safety Culture (MO SOPS) to Version 2.0, with New Workplace Safety Supplemental Items for Medical Offices	Form and Instruction	New	Pretest of SOPS Medical Office Survey 2.0 and Workplace Safety Supplemental Items - REVISED
276298	Pretest of the Proposed Revisions to the Medical Office Survey on Patient Safety Culture (MO SOPS) to Version 2.0, with New Workplace Safety Supplemental Items for Medical Offices	Form and Instruction	New	Medical Office Background Information Form
276298	Pretest of the Proposed Revisions to the Medical Office Survey on Patient Safety Culture (MO SOPS) to Version 2.0, with New Workplace Safety Supplemental Items for Medical Offices	Form and Instruction	New	Medical Office Point of Contact (POC) Instructions
267558	Pilot Test of Proposed Revisions to the Nursing Home Survey on Patient Safety Culture (NH SOPS) to Version 2.0, with the Workplace Safety Supplemental Item Set for Nursing Homes	Form and Instruction	New	SOPS Nursing Home Survey with Workplace Safety Supplemental Item Set
263760	Provider Focus Group	Form and Instruction	Unchanged	Provider Focus Group
263760	Provider Focus Group	Form and Instruction	Unchanged
263759	Provider and Patient Interview	Form and Instruction	Unchanged	Provider and Patient Interview
263759	Provider and Patient Interview	Form and Instruction	Unchanged
263758	Patient and Caregiver Usability Interview	Form and Instruction	Unchanged	Patient and Caregiver Usability Interview
263758	Patient and Caregiver Usability Interview	Form and Instruction	Unchanged
263757	Patient and Caregiver Survey	Form and Instruction	Unchanged	Patient and Caregiver Survey
263757	Patient and Caregiver Survey	Form and Instruction	Unchanged
252822	MEPS Alternative Sampling Design Pilot Test	Form and Instruction	Unchanged	Pilot Screener
252822	MEPS Alternative Sampling Design Pilot Test	Form and Instruction	Unchanged
251475	Feasibility Study for a MEPS Monthly Check-In	Instruction	Unchanged
251475	Feasibility Study for a MEPS Monthly Check-In	Form and Instruction	Unchanged	Attachment 2-E. Study 2 MCI Protocol
251475	Feasibility Study for a MEPS Monthly Check-In	Form and Instruction	Unchanged	Attachment 2-B. Study 2 Recruitment telephone script + scheduling MCI interview
251475	Feasibility Study for a MEPS Monthly Check-In	Form and Instruction	Unchanged	Attachment 1-I. Study 1 MEPS Abbreviated R2 Interview
251475	Feasibility Study for a MEPS Monthly Check-In	Form and Instruction	Unchanged	Attachment 1-H. Study 1 Protocol 3 (R2)
251475	Feasibility Study for a MEPS Monthly Check-In	Form and Instruction	Unchanged	Attachment 1-G. Study 1 MCI Protocol 2
251475	Feasibility Study for a MEPS Monthly Check-In	Form and Instruction	Unchanged	Attachment 1-F. Study 1 MCI Protocol 1
251475	Feasibility Study for a MEPS Monthly Check-In	Form and Instruction	Unchanged	Attachment 1-B. Study 1 Recruitment screener
251475	Feasibility Study for a MEPS Monthly Check-In	Form and Instruction	Unchanged	Attachment 1-B. Study 1 Recruitment screener
251475	Feasibility Study for a MEPS Monthly Check-In	Form and Instruction	Unchanged
251418	Pilot Test of the Proposed Workplace Safety Supplemental Item Set For the AHRQ Surveys on Patient Safety Culture™ (SOPS®) Nursing Home Survey	Form and Instruction	Unchanged	Nursing Home Background Information Form
251418	Pilot Test of the Proposed Workplace Safety Supplemental Item Set For the AHRQ Surveys on Patient Safety Culture™ (SOPS®) Nursing Home Survey	Form and Instruction	Unchanged	Attachment A: Draft Workplace Safety Supplemental Item Set
251418	Pilot Test of the Proposed Workplace Safety Supplemental Item Set For the AHRQ Surveys on Patient Safety Culture™ (SOPS®) Nursing Home Survey	Form and Instruction	Unchanged	Attachment C: Nursing Home Point of Contact (POC) Instructions
251418	Pilot Test of the Proposed Workplace Safety Supplemental Item Set For the AHRQ Surveys on Patient Safety Culture™ (SOPS®) Nursing Home Survey	Form and Instruction	Unchanged	Attachment B: Draft Workplace Safety Cognitive Interview Guide
251418	Pilot Test of the Proposed Workplace Safety Supplemental Item Set For the AHRQ Surveys on Patient Safety Culture™ (SOPS®) Nursing Home Survey	Form and Instruction	Unchanged
249349	Field Test of A Survey of End-of-Life Care	Form and Instruction	Unchanged	Survey of End-of-Life Care
249349	Field Test of A Survey of End-of-Life Care	Form and Instruction	Unchanged
246524	Pilot Test of the Revised Data Collection Method for the Medical Expenditure Panel Survey - Insurance Component	Form and Instruction	Unchanged	Pilot test – Plan Questionnaire
246524	Pilot Test of the Revised Data Collection Method for the Medical Expenditure Panel Survey - Insurance Component	Form and Instruction	Unchanged	Pilot test – Establishment Questionnaire
246524	Pilot Test of the Revised Data Collection Method for the Medical Expenditure Panel Survey - Insurance Component	Form and Instruction	Unchanged

ICR Details

OMB Control No: 0935-0124	ICR Reference No: 202401-0935-006
Status: Active	Previous ICR Reference No: 202009-0935-003
Agency/Subagency: HHS/AHRQ	Agency Tracking No: 3rw3t
Title: Questionnaire and Data Collection Testing, Evaluation, and Research for the Agency for Healthcare Research and Quality
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 with change	Conclusion Date: 03/06/2024
Retrieve Notice of Action (NOA)	Date Received in OIRA: 01/31/2024
Terms of Clearance: HHS will submit individual collections under this generic clearance to OMB. These submissions will include the actual study instruments along with a memo describing the specific study goal, the study design, any incentives to be used, and the sampling and analysis plans.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2027	36 Months From Approved	03/31/2024
Responses	13,800	0	13,800
Time Burden (Hours)	8,900	0	8,900
Cost Burden (Dollars)	0	0	0

---

Abstract: Work conducted under this clearance is intended to improve AHRQ's current data collections by developing new surveys and revising surveys and to test survey instruments more quickly.

---

Authorizing Statute(s): None

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:
	88 FR 77588	11/13/2023
30-day Notice:	Federal Register Citation:	Citation Date:
	89 FR 5546	01/29/2024
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 14

table that charts list of burden

IC Title	Form No.	Form Name
Feasibility Study for a MEPS Monthly Check-In	1B, 1C, 1F, 1G, 1H, 2B, 2E, 1I	Attachment 1-B. Study 1 Recruitment screener ,   Attachment 1-B. Study 1 Recruitment screener ,   Attachment 1-F. Study 1 MCI Protocol 1 ,   Attachment 1-G. Study 1 MCI Protocol 2 ,   Attachment 1-H. Study 1 Protocol 3 (R2) ,   Attachment 1-I. Study 1 MEPS Abbreviated R2 Interview ,   Attachment 2-B. Study 2 Recruitment telephone script + scheduling MCI interview ,   Attachment 2-E. Study 2 MCI Protocol
Field Test of A Survey of End-of-Life Care	1	Survey of End-of-Life Care
MEPS Alternative Sampling Design Pilot Test	1	Pilot Screener
MEPS-HC Address-Based Sample (ABS) Field Test	N/A, N/A, N/A	Attachment 6 - Round 1 Enumeration ,   Attachment 7 Round 1 Re-Enumeration ,   Attachment 5- Pre R1 Questionnaire
MEPS-HC Cognitive Testing	4, 1, 2, 3	Attachment 1- Cognitive Testing Materials for Pre- R1 ,   Attachment 2- Cognitive Testing Materials for Health Care Entry ,   Attachment 3- Blue Button Access Authorization Script ,   Attachment 4- Generic claims authorization script
MEPS-HC Exited Respondents Administrative Data Access	1	Attachment 1- Exit Panel CMS Administrative Data Access Authorization
Patient and Caregiver Survey	1	Patient and Caregiver Survey
Patient and Caregiver Usability Interview	1	Patient and Caregiver Usability Interview
Pilot Test of Proposed Revisions to the Nursing Home Survey on Patient Safety Culture (NH SOPS) to Version 2.0, with the Workplace Safety Supplemental Item Set for Nursing Homes	1	SOPS Nursing Home Survey with Workplace Safety Supplemental Item Set
Pilot Test of the Proposed Workplace Safety Supplemental Item Set For the AHRQ Surveys on Patient Safety Culture™ (SOPS®) Nursing Home Survey	1, 2, 3, Attachment F	Attachment B: Draft Workplace Safety Cognitive Interview Guide ,   Attachment C: Nursing Home Point of Contact (POC) Instructions ,   Attachment A: Draft Workplace Safety Supplemental Item Set ,   Nursing Home Background Information Form
Pilot Test of the Revised Data Collection Method for the Medical Expenditure Panel Survey - Insurance Component	1, 2	Pilot test – Establishment Questionnaire ,   Pilot test – Plan Questionnaire
Pretest of the Proposed Revisions to the Medical Office Survey on Patient Safety Culture (MO SOPS) to Version 2.0, with New Workplace Safety Supplemental Items for Medical Offices	3, 5, 4, 1, 2, 6	Medical Office Point of Contact (POC) Instructions ,   Medical Office Background Information Form ,   Pretest of SOPS Medical Office Survey 2.0 and Workplace Safety Supplemental Items - REVISED ,   Attachment B - Medical Office Data Use Agreement (DUA) - REVISED ,   MO Survey Version 2.0 and Workplace Safety Supplemental Items Cognitive Interview Guide - REVISED
Provider Focus Group	1	Provider Focus Group
Provider and Patient Interview	1	Provider and Patient Interview

---

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	13,800	13,800	0	0	0	0
Annual Time Burden (Hours)	8,900	8,900	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: $708,613

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: 01/31/2024

---