0990-PatientPerspective_App J2 Focus Group Postcard

0990-PatientPerspective_App J2 Focus Group Postcard.doc

Patient Perpective of Delivery of Health Care Through the use of an Electronic Health Record Survey

0990-PatientPerspective_App J2 Focus Group Postcard

OMB: 0990-0361

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O MB Approval No: 0990-NEW

Approval Expires: xx/xx/20xx




CONTENT OF FOCUS GROUP POSTCARD SIDE 1

Card number

Filled by office

Office number: ____

Sheet number: ____

Line number: ____

Name: _________________________________________________________

Address: ____________________________________________________________

City, State, Zip: _______________________________________________________

Primary telephone number: ( _ _ _ ) _ _ _ - _ _ _ _

Alternate telephone number: ( _ _ _ ) _ _ _ - _ _ _ _

Email address: ____________________@ ____________________________

Do you prefer to be contacted by : [ ] phone

[ ] email

CONTENT OF FOCUS GROUP POSTCARD SIDE 2Please mark these three items about yourself.

Gender (please check one):

[ ] Male

[ ] Female

Age group (please check one):

[ ] 18 - 64 years

[ ] 65 years or older

Race/ethnicity (please mark one or more):

[ ] American Indian or Alaska Native

[ ] Asian

[ ] African American/Black

[ ] Native Hawaiian or other Pacific Islander

[ ] White

[ ] Hispanic or Latino/Latina


According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0990- . The time required to complete this information collection is estimated to average one minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer

J.5

File Typeapplication/msword
File TitleOMB Approval No: 0990-NEW
AuthorKBogen
Last Modified ByDHHS
File Modified2010-04-21
File Created2010-04-20

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