Form #4 Form #4 Workflow Assessment Usage Log

Attachment D: Workflow Assessment Usage Log

Form Approved
OMB No. 0935-XXXX
Exp. Date XX/XX/20XX

Clinic Name: __________________________________

Practice staff name: ____________________________

Role: ________________________________________

Note: This form will help the clinic study team keep a record of how you have used the Workflow toolkit and should be completed weekly. If you have questions about using this form, contact Dr. Paul Gorman at (503) 494-4025 or your Practice Enhancement Research Coordinator (PERC) at (503) 494-1583.

No.	Date	Activity	Outcome
	Example: 12/20/2011	Example: Tried to read about how workflow has been impacted for other clinics installing EPIC software and how they tracked lab values.	Example: Tried to download a PDF, but my computer timed out and the link didn’t seem to work.
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Add additional rows as needed to include all workflow toolkit usage activities and outcomes

Public reporting burden for this collection of information is estimated to average 15 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-XXXX) AHRQ, 540 Gaither Road, Room # 5036, Rockville, MD 20850.