Field Test of A Survey of End-of-Life Care

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

Documents and Forms

Document Name Document Type
Form 1 Field Test of A Survey of End-of-Life Care Form and Instruction
1 Survey of End-of-Life Care Appendix A Survey of EOL Care 2021_9_16eb.docx Form and Instruction
1 Survey of End-of-Life Care Appendix A Survey of EOL Care 2021_9_16eb.docx Form and Instruction
Appendix B Survey of EOL Care Cover Letter and Telephone Intro_2021_9_15.docx Survey Cover Letter and Telephone Interview Introduction IC Document
Appendix B Survey of EOL Care Cover Letter and Telephone Intro_2021_9_15.docx Survey Cover Letter and Telephone Interview Introduction IC Document
EOL Care Survey Statement A DRAFT 2021_9_16eb.docx Supporting Statement Part A IC Document
EOL Care Survey Statement A DRAFT 2021_9_16eb.docx Supporting Statement Part A IC Document
EOL Care Survey Statement B DRAFT 2021_9_10.docx Supporting Statement Part B IC Document
EOL Care Survey Statement B DRAFT 2021_9_10.docx Supporting Statement Part B IC Document
Cover Letter Survey of EOL Care 2021_9_15eb.docx AHRQ Cover Letter IC Document
Cover Letter Survey of EOL Care 2021_9_15eb.docx AHRQ Cover Letter IC Document

Information Collection (IC) Details

IC Title:	Field Test of A Survey of End-of-Life Care	Agency IC Tracking Number:

IC Status: Unchanged

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	1	Survey of End-of-Life Care	Appendix A Survey of EOL Care 2021_9_16eb.docx		No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 510	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Previously Approved
Annual Number of Responses for this IC	510	510
Annual IC Time Burden (Hours)	97	97
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Survey Cover Letter and Telephone Interview Introduction	Appendix B Survey of EOL Care Cover Letter and Telephone Intro_2021_9_15.docx	09/16/2021
Supporting Statement Part A	EOL Care Survey Statement A DRAFT 2021_9_16eb.docx	09/16/2021
Supporting Statement Part B	EOL Care Survey Statement B DRAFT 2021_9_10.docx	09/16/2021
AHRQ Cover Letter	Cover Letter Survey of EOL Care 2021_9_15eb.docx	09/16/2021

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