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Appendix B1. HSA Interview Guide
Evaluation of Learning Health Systems K12 Training Program
OMB: 0935-0255
IC ID: 242176
OMB.report
HHS/AHRQ
OMB 0935-0255
ICR 202006-0935-001
IC 242176
( )
Documents and Forms
Document Name
Document Type
Form B1
Appendix B1. HSA Interview Guide
Form
B1 Appendix B1. HSA Interview Guide
Appendix B1. HSA Discussion Guide_5-18-20.docx
Form
Appendix B2. HSA Invitation Email.docx
Appendix B2. HSA Invitation Email
IC Document
Appendix B3. HSA FAQs.docx
Appendix B3. HSA Study Description/FAQs
IC Document
Appendix B4. HSA Invitation Reminder Email.docx
Appendix B4. HSA Invitation Reminder Email
IC Document
Appendix B5. HSA Recruitment Telephone Script.docx
Appendix B5. HSA Telephone Recruitment Script
IC Document
Appendix B6. HSA Scheduling Email.docx
Appendix B6. HSA Scheduling Email
IC Document
Appendix B7. HSA Confirmation Email.docx
Appendix B7. HSA Confirmation Email
IC Document
Appendix B8. HSA Interview Reminder Email.docx
Appendix B8. HSA Reminder Email
IC Document
Appendix B9. HSA Reminder Telephone Script.docx
Appendix B9. HSA Reminder Telephone Script
IC Document
Appendix B10. HSA Thank You Email.docx
Appendix B10. HSA Thank-You Email
IC Document
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Appendix B1. HSA Interview Guide
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
B1
Appendix B1. HSA Interview Guide
Appendix B1. HSA Discussion Guide_5-18-20.docx
Yes
Yes
Fillable Printable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Health Care Services
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
39
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:
50 %
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
39
0
39
0
0
0
Annual IC Time Burden (Hours)
39
0
39
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
Appendix B2. HSA Invitation Email
Appendix B2. HSA Invitation Email.docx
06/05/2020
Appendix B3. HSA Study Description/FAQs
Appendix B3. HSA FAQs.docx
06/05/2020
Appendix B4. HSA Invitation Reminder Email
Appendix B4. HSA Invitation Reminder Email.docx
06/05/2020
Appendix B5. HSA Telephone Recruitment Script
Appendix B5. HSA Recruitment Telephone Script.docx
06/05/2020
Appendix B6. HSA Scheduling Email
Appendix B6. HSA Scheduling Email.docx
06/05/2020
Appendix B7. HSA Confirmation Email
Appendix B7. HSA Confirmation Email.docx
06/05/2020
Appendix B8. HSA Reminder Email
Appendix B8. HSA Interview Reminder Email.docx
06/05/2020
Appendix B9. HSA Reminder Telephone Script
Appendix B9. HSA Reminder Telephone Script.docx
06/05/2020
Appendix B10. HSA Thank-You Email
Appendix B10. HSA Thank You Email.docx
06/05/2020
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.