2 Process Usage Worksheet (Patients)

Form Approved
OMB No. 0935-0179
Exp. Date 11/30/2020

Attachment C. Process Usage Worksheet (Patients)

To understand the provider organization’s view of patient use of the PRO application each site lead will complete a brief usage process worksheet. This worksheet will be another lens on how the PRO application is being used by patients.

We will collect four data points each week. These data points are:

1. Number of eligible patients: defined as the number of patients that meet PRO application use criteria.

2. Number of patients declining the PRO tablet: defined as the number of patients that were asked to complete the PRO measure but declined to use the tablet.

3. Number of patients who received the PRO tablet: defined as the number of patients who actually agree to complete the PRO measure and accept the tablet.

4. Number of patients completing the PRO measure: defined as the number of patients that say they completed the PRO measure.

The worksheet is displayed below and will be completed on a weekly basis by the lead at each site and then confirmed by our research team.

	Number of eligible patients	Number of patients declining PRO tablet	Number of patients who received the PRO tablet	Number of patients completing the PRO measure
Week 1
Week 2
Week 3
Week 4
Week 5
Week 6
Week 7
Week 8
Week 9
Week 10
Week 11
Week 12

Public reporting burden for this collection of information is estimated to average 5 minutes per response, the estimated time required to complete the survey. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-0179) AHRQ, 5600 Fishers Lane, # 07W41A, Rockville, MD 20857.

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