Implementation of an Electronic Care Plan for People with Multiple Chronic Conditions

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

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0935-0124 can be found here:

Documents and Forms

Document Name Document Type
Form 1 Implementation of an Electronic Care Plan for People with Multiple Chronic Conditions Form and Instruction
1 Attachment A - Healthcare Staff Interview Guide (for pro Attachment A - Healthcare Staff Interview Guide (for providers & non-providers)_051420.docx Form and Instruction
2 Attachment B - Health Information Technology Professiona Attachment B - Health Information Technology Professional Interview Guide_051420.docx Form and Instruction
3 Attachment C - Patient Interview Guide Attachment C - Patient Interview Guide_051420.docx Form and Instruction
OMB Supporting Statement_E-Care_051420.docx Supporting Statement IC Document
OMB Cover Letter.docx Cover Letter IC Document

Information Collection (IC) Details

IC Title:	Implementation of an Electronic Care Plan for People with Multiple Chronic Conditions	Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Electronic Capability
Form and Instruction	1	Attachment A - Healthcare Staff Interview Guide (for providers & non-providers)	Attachment A - Healthcare Staff Interview Guide (for providers & non-providers)_051420.docx	No	Paper Only
Form and Instruction	2	Attachment B - Health Information Technology Professional Interview Guide	Attachment B - Health Information Technology Professional Interview Guide_051420.docx	No	Paper Only
Form and Instruction	3	Attachment C - Patient Interview Guide	Attachment C - Patient Interview Guide_051420.docx	No	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 34	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 Agency Discretion
Annual Number of Responses for this IC	34	34
Annual IC Time Burden (Hours)	34	34
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Supporting Statement	OMB Supporting Statement_E-Care_051420.docx	05/15/2020
Cover Letter	OMB Cover Letter.docx	05/15/2020

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.