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Federal forms, ICRs, and supporting documents

Information Collection

Field Test of A Survey of End-of-Life Care

IC 249349 under ICR 202401-0935-006 · OMB 0935-0124.

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Information Collection (IC) Details

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Field Test of A Survey of End-of-Life Care
 
Unchanged
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction 1 Survey of End-of-Life Care Appendix A Survey of EOL Care 2021_9_16eb.docx No   Paper Only

Health Health Care Services

 

510 0
   
Individuals or Households
 
   0 %

  Requested Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 510 0 0 0 0 510
Annual IC Time Burden (Hours) 97 0 0 0 0 97
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Survey Cover Letter and Telephone Interview Introduction Appendix B Survey of EOL Care Cover Letter and Telephone Intro_2021_9_15.docx 09/16/2021
Supporting Statement Part A EOL Care Survey Statement A DRAFT 2021_9_16eb.docx 09/16/2021
Supporting Statement Part B EOL Care Survey Statement B DRAFT 2021_9_10.docx 09/16/2021
AHRQ Cover Letter Cover Letter Survey of EOL Care 2021_9_15eb.docx 09/16/2021
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.