Attachment H – Learning Community Follow-up Survey

Evaluating the Implementation of PCOR to Increase Referral, Enrollment, and Retention through Automatic Referral to Cardiac Rehabilitation (CR) with Care Coordinator

Documents and Forms

Document Name Document Type
Form 5 Attachment H – Learning Community Follow-up Survey Form and Instruction
5 Attachment H – Learning Community Follow-up Survey Attachment H. Learning Community Follow-up Survey (2020-01-08).docx Form and Instruction

Information Collection (IC) Details

IC Title:	Attachment H – Learning Community Follow-up Survey	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 and Instruction	5	Attachment H – Learning Community Follow-up Survey	Attachment H. Learning Community Follow-up Survey (2020-01-08).docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 120	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: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	120	120
Annual IC Time Burden (Hours)	20	20
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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