OMB control number

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

OMB 0935-0124 · HHS/AHRQ.

OMB 0935-0124

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.

The latest form for Questionnaire and Data Collection Testing, Evaluation, and Research for the Agency for Healthcare Research and Quality expires 2027-03-31 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form 1 Provider Focus Group Form and Instruction
Form 1 Provider and Patient Interview Form and Instruction
Form 1 Patient and Caregiver Usability Interview Form and Instruction
Form 1 Patient and Caregiver Survey Form and Instruction
Form 1 MEPS Alternative Sampling Design Pilot Test Form and Instruction
Form 1B Feasibility Study for a MEPS Monthly Check-In Form and Instruction
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
Form 1 Field Test of A Survey of End-of-Life Care Form and Instruction
Form 1 Pilot Test of the Revised Data Collection Method for the Medical Expenditure Panel Survey - Insurance Component Form and Instruction
Attachment D - Generic Clearance Submission.docx Supplementary Document
Attachment B - Data Collections under Generic 0935-0124.docx (document unavailable) Supplementary Document
Attachment A - Healthcare Research and Quality Act of 1999.pdf Supplementary Document
Supporting Statement Part B - Generic 0935-0124 Questionnaire and Data Collection Testing, Evaluation and Research.docx (document unavailable) Supporting Statement B
Supporting Statement Part A - Generic 0935-0124 Questionnaire and Data Collection Testing Evaluation and Research_012524.docx (document unavailable) Supporting Statement A
Provider Focus Group Form and Instruction
Provider and Patient Interview Form and Instruction
Patient and Caregiver Usability Interview Form and Instruction
Patient and Caregiver Survey Form and Instruction
MEPS Alternative Sampling Design Pilot Test Form and Instruction
Feasibility Study for a MEPS Monthly Check-In Form and Instruction
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
Field Test of A Survey of End-of-Life Care Form and Instruction
Pilot Test of the Revised Data Collection Method for the Medical Expenditure Panel Survey - Insurance Component Form and Instruction

All Historical Document Collections

202401-0935-006 Approved with change	Extension without change of a currently approved collection	2024-01-31
202009-0935-003	Extension without change of a currently approved collection	2020-10-27
201708-0935-002 Approved without change	Extension without change of a currently approved collection	2017-08-07
201409-0935-002 Approved with change	Reinstatement without change of a previously approved collection	2014-09-09
201104-0935-002 Approved with change	Extension without change of a currently approved collection	2011-04-08
200801-0935-001 Approved without change	Revision of a currently approved collection	2008-01-28
200606-0935-002 Approved without change	No material or nonsubstantive change to a currently approved collection	2006-06-01
200411-0935-001 Approved with change	New collection (Request for a new OMB Control Number)	2004-11-15

OMB Details

Pilot Test of the Revised Data Collection Method for the Medical Expenditure Panel Survey - Insurance Component

Federal Enterprise Architecture: Health - Health Care Services

Form 1	Pilot test – Establishment Questionnaire	Fillable Fileable	Form and instruction
Form 2	Pilot test – Plan Questionnaire	Fillable Fileable	Form and instruction

Review document collections for all forms, instructions, and supporting documents - including paper/printable forms.