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Pretest for the Medical Office VE survey
Pilot Test of the Proposed Value and Efficiency Surveys and Communicating About Value Checklist
OMB: 0935-0211
IC ID: 206676
OMB.report
HHS/AHRQ
OMB 0935-0211
ICR 201304-0935-003
IC 206676
( )
Documents and Forms
Document Name
Document Type
Form Form #4
Pretest for the Medical Office VE survey
Form and Instruction
Form #4 Pretest Survey for Medical Office VE Survey
Attachment D - Pretest Survey for Medical Office VE Survey_1-17-13.docx
Form and Instruction
Attachment H - Pretest Cover Letter and Reminder Notice for Medical Office VE Survey.docx
Attachment H - Pretest Cover Letter and Reminder Notice for Medical Office VE Survey
IC Document
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Pretest for the Medical Office VE survey
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
New
Obligation to Respond:
Voluntary
CFR Citation:
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form and Instruction
Form #4
Pretest Survey for Medical Office VE Survey
Attachment D - Pretest Survey for Medical Office VE Survey_1-17-13.docx
Yes
Yes
Paper Only
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Consumer Health and Safety
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
504
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:
0 %
Approved
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
504
0
504
0
0
0
Annual IC Time Burden (Hours)
126
0
126
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
Attachment H - Pretest Cover Letter and Reminder Notice for Medical Office VE Survey
Attachment H - Pretest Cover Letter and Reminder Notice for Medical Office VE Survey.docx
04/18/2013
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.