Information Collection

Pilot Study of Proposed Medical Office Surveys on Patient Safety

IC 178947 under ICR 200703-0935-001 · OMB 0935-0131.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Attachment B-Amb patient safety culture survey draft 2-5-07.pdf	Other-Draft Questionnaire

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation: 5 CFR 1320.5

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Draft Questionnaire			Attachment B-Amb patient safety culture survey draft 2-5-07.pdf		No	No	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,638

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,638	1,638
Annual IC Time Burden (Hours)	410	410
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.