Form 0920-0234 Set-up Fee Questionnaire (2024)

Attachment K: Set-Up Fee Questionnaire
Form Approved
OMB No. 0920-0234
Exp. date XX/XX/20XX
Notice – Public reporting burden of this collection of information is estimated to average 15 minutes per response, including the time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the
collection of information. 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: CDC/ATSDR Information Collection Review Office; 1600 Clifton Road, MS
H21-8, Atlanta, GA 30333, ATTN: PRA (0920-0234).
Assurance of Confidentiality – We take your privacy very seriously. All information that relates to or describes identifiable characteristics of
individuals, a practice, or an establishment will be used only for statistical purposes. NCHS staff, contractors, and agents will not disclose or
release responses in identifiable form without the consent of the individual or establishment in accordance with section 308(d) of the Public
Health Service Act (42 U.S.C. 242m(d)) and the Confidential Information Protection and Statistical Efficiency Act or CIPSEA (44 U.S.C.
3561-3583). In accordance with CIPSEA, every NCHS employee, contractor, and agent has taken an oath and is subject to a jail term of up to
five years, a fine of up to $250,000, or both if he or she willfully discloses ANY identifiable information about you. In addition to the above
cited laws, NCHS complies with the Federal Cybersecurity Enhancement Act of 2015 (6 U.S.C. §§ 151 and 151 note) which protects Federal
information systems from cybersecurity risks by screening their networks.

1. Please confirm contact information below:
Payee:
Attn:
Job Title:
Address:
/
City/State/ZIP Code:
Telephone Number:
Extension:
E-mail:

/

2. Please provide the total number or estimate of visits WITH EHR for your HC:
$
3.Total Set-Up Fee Issued:
4. To gauge the costs sustained by installing the National Health Care Survey EHR module, we wanted to ask what costs
your HC incurred during IG and transmission set-up and how your set-up fee was utilized:
Category
Utilized (check box)
Estimate amount of money
HC IT staff
$
EHR vendor staff
$
Installation and configuration
$
Hardware
$
Software
$
Health Information Service Provider (HISP)
$
Other: please specify below:
$

5. Did your center incur more than $10,000 worth of costs?
•

•

Total $

Yes
a. If so, how much did it cost for your center to participate?
• __________
b. If so, what was the biggest cost?
•
No

__________