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 is listed under ICR 202401-0935-006.

View the official OMB control history on Reginfo.gov.

Latest Forms, Documents, and Supporting Material

Latest forms, documents, and information collections
Document	Type
Attachment 5- Pre R1 Questionnaire (document unavailable)	Form and Instruction
Attachment 7 Round 1 Re-Enumeration (document unavailable)	Form and Instruction
Attachment 6 - Round 1 Enumeration (document unavailable)	Form and Instruction
Form 4 Attachment 4- Generic claims authorization script (document unavailable)	Form and Instruction
Form 3 Attachment 3- Blue Button Access Authorization Script (document unavailable)	Form and Instruction
Form 2 Attachment 2- Cognitive Testing Materials for Health Care Entry (document unavailable)	Form and Instruction
Form 1 Attachment 1- Cognitive Testing Materials for Pre- R1 (document unavailable)	Form and Instruction
Form 1 Attachment 1- Exit Panel CMS Administrative Data Access Authorization (document unavailable)	Form and Instruction
Form 1, 2 MO Survey Version 2.0 and Workplace Safety Supplemental Items Cognitive Interview Guide - REVISED (document unavailable)	Form and Instruction
Form 4 Attachment B - Medical Office Data Use Agreement (DUA) - REVISED (document unavailable)	Form and Instruction
Form 6 Pretest of SOPS Medical Office Survey 2.0 and Workplace Safety Supplemental Items - REVISED (document unavailable)	Form and Instruction
Form 5 Medical Office Background Information Form (document unavailable)	Form and Instruction
Form 3 Medical Office Point of Contact (POC) Instructions (document unavailable)	Form and Instruction
Form 1 SOPS Nursing Home Survey with Workplace Safety Supplemental Item Set (document unavailable)	Form and Instruction
Form 1 Provider Focus Group	Form and Instruction
Form 1 Provider Focus Group	Form and Instruction
Form 1 Provider and Patient Interview	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 Usability Interview	Form and Instruction
Form 1 Patient and Caregiver Survey	Form and Instruction
Form 1 Patient and Caregiver Survey	Form and Instruction
Form 1 Pilot Screener	Form and Instruction
Form 1 MEPS Alternative Sampling Design Pilot Test	Form and Instruction
Form 2E Attachment 2-E. Study 2 MCI Protocol	Form and Instruction
Form 2B Attachment 2-B. Study 2 Recruitment telephone script + scheduling MCI interview	Form and Instruction
Form 1I Attachment 1-I. Study 1 MEPS Abbreviated R2 Interview	Form and Instruction
Form 1H Attachment 1-H. Study 1 Protocol 3 (R2)	Form and Instruction
Form 1G Attachment 1-G. Study 1 MCI Protocol 2	Form and Instruction
Form 1F Attachment 1-F. Study 1 MCI Protocol 1	Form and Instruction
Form 1C Attachment 1-B. Study 1 Recruitment screener	Form and Instruction
Form 1B Attachment 1-B. Study 1 Recruitment screener	Form and Instruction
Form 1B Feasibility Study for a MEPS Monthly Check-In	Form and Instruction
Form Attachment F Nursing Home Background Information Form	Form and Instruction
Form 3 Attachment A: Draft Workplace Safety Supplemental Item Set	Form and Instruction
Form 2 Attachment C: Nursing Home Point of Contact (POC) Instructions	Form and Instruction
Form 1 Attachment B: Draft Workplace Safety Cognitive Interview Guide	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 Survey of End-of-Life Care	Form and Instruction
Form 1 Field Test of A Survey of End-of-Life Care	Form and Instruction
Form 2 Pilot test – Plan Questionnaire	Form and Instruction
Form 1 Pilot test – Establishment Questionnaire	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	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	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
MEPS-HC Address-Based Sample (ABS) Field Test	Form and Instruction
MEPS-HC Address-Based Sample (ABS) Field Test	Form and Instruction
MEPS-HC Address-Based Sample (ABS) Field Test	Form and Instruction
MEPS-HC Cognitive Testing	Form and Instruction
MEPS-HC Cognitive Testing	Form and Instruction
MEPS-HC Cognitive Testing	Form and Instruction
MEPS-HC Cognitive Testing	Form and Instruction
MEPS-HC Exited Respondents Administrative Data Access	Form and Instruction
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
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
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
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
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
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
Provider Focus Group	Form and Instruction
Provider Focus Group	Form and Instruction
Provider and Patient Interview	Form and Instruction
Provider and Patient Interview	Form and Instruction
Patient and Caregiver Usability Interview	Form and Instruction
Patient and Caregiver Usability Interview	Form and Instruction
Patient and Caregiver Survey	Form and Instruction
Patient and Caregiver Survey	Form and Instruction
MEPS Alternative Sampling Design Pilot Test	Form and Instruction
MEPS Alternative Sampling Design Pilot Test	Form and Instruction
Feasibility Study for a MEPS Monthly Check-In	Instruction
Feasibility Study for a MEPS Monthly Check-In	Form and Instruction
Feasibility Study for a MEPS Monthly Check-In	Form and Instruction
Feasibility Study for a MEPS Monthly Check-In	Form and Instruction
Feasibility Study for a MEPS Monthly Check-In	Form and Instruction
Feasibility Study for a MEPS Monthly Check-In	Form and Instruction
Feasibility Study for a MEPS Monthly Check-In	Form and Instruction
Feasibility Study for a MEPS Monthly Check-In	Form and Instruction
Feasibility Study for a MEPS Monthly Check-In	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
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
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
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
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
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
Pilot Test of the Revised Data Collection Method for the Medical Expenditure Panel Survey - Insurance Component	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

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

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

Information collection instruments
Form	Name	Electronic access	Type
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.