Information Collection

Agency for Healthcare Research and Quality (AHRQ) Quality Indicators (QI) Module-specific User Survey

IC 283247 under ICR 202610-0935-001 · OMB 0935-0179.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Maternal Health Indicators (MHI) Module Specific Feedback Agency for Healthcare Research and Quality (AHRQ) Quality Indicators (QI) Module-specific User Survey	Form and Instruction
Maternal Health Indicators (MHI) Module Specific Feedbac MHI_module specific_Feedback_Survey_2026_clean.docx	Form and Instruction
Generic 0935-0179 Short-Form Template QI Module-Specific_final.docx Generic Short Form QI Module Specific	IC Document

IC Title:

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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	N/A				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 400

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: 100 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	400	400
Annual IC Time Burden (Hours)	67	67
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Generic Short Form QI Module Specific		10/23/2026

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

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