Requirements for Collection of Data Relating to the Prevention of Medical Gas Mix-ups at Health Care Facilities Survey

ICR 200406-0910-006

OMB: 0910-0548

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
ICR Details
0910-0548 200406-0910-006
Historical Active
HHS/FDA
Requirements for Collection of Data Relating to the Prevention of Medical Gas Mix-ups at Health Care Facilities Survey
New collection (Request for a new OMB Control Number)   No
Regular
Approved with change 09/29/2004
Retrieve Notice of Action (NOA) 06/30/2004
Approved for 18 months on the following conditions: FDA shall pretest the questionnaire on a handful of facilities to refine the questions. FDA shall submit the final versions of the questionnaire and the revised letter to the District Offices which includes instructions on how to randomize the sample of facilities that will receive the questionnaire for OMB review and approval prior to initiating the survey.
  Inventory as of this Action Requested Previously Approved
03/31/2006 03/31/2006
1 0 0
71 0 0
0 0 0

This survey will derive information from health care facilities such as hospitals and nursing homes to assess the effectiveness of implementing recommendations on the prevention of medical gas mix-ups.

None
None


No

1
IC Title Form No. Form Name
Requirements for Collection of Data Relating to the Prevention of Medical Gas Mix-ups at Health Care Facilities Survey

  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 1 0 0 1 0 0
Annual Time Burden (Hours) 71 0 0 71 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
No

$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected

  No

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
06/30/2004


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