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ECHO National Nursing Home COVID-19 Action Network Customer Satisfaction Survey
Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery
OMB: 0935-0179
IC ID: 246687
OMB.report
HHS/AHRQ
OMB 0935-0179
ICR 202310-0935-001
IC 246687
( )
Documents and Forms
Document Name
Document Type
Form 1
ECHO National Nursing Home COVID-19 Action Network Customer Satisfaction Survey
Form and Instruction
1 Appendix A
Appendix A AHRQ ECHO National Nursing Home Initiative 04-06-2021 Revised.docx
Form and Instruction
1 Appendix A
Appendix A AHRQ ECHO National Nursing Home Initiative 04-06-2021 Revised.docx
Form and Instruction
OMB Cover Letter.docx
Cover Letter
IC Document
OMB Cover Letter.docx
Cover Letter
IC Document
Supporting Statment A 04012021 eb 04-06-2021 po clean.docx
Supporting Statement
IC Document
Supporting Statment A 04012021 eb 04-06-2021 po clean.docx
Supporting Statement
IC Document
Appendix A AHRQ ECHO National Nursing Home Initiative 04-06-2021.docx
Appendix A
IC Document
Appendix A AHRQ ECHO National Nursing Home Initiative 04-06-2021.docx
Appendix A
IC Document
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
ECHO National Nursing Home COVID-19 Action Network Customer Satisfaction Survey
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
Appendix A
Appendix A AHRQ ECHO National Nursing Home Initiative 04-06-2021 Revised.docx
No
Paper Only
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:
4,571
Number of Respondents for Small Entity:
0
Affected Public:
Private Sector
Private Sector:
Not-for-profit institutions, Businesses or other for-profits
Percentage of Respondents Reporting Electronically:
0 %
Requested
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
4,571
0
0
0
0
4,571
Annual IC Time Burden (Hours)
505
0
0
0
0
505
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
Cover Letter
OMB Cover Letter.docx
04/06/2021
Supporting Statement
Supporting Statment A 04012021 eb 04-06-2021 po clean.docx
04/06/2021
Appendix A
Appendix A AHRQ ECHO National Nursing Home Initiative 04-06-2021.docx
04/06/2021
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.