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

Document Name Document Type
Attachment B-Amb patient safety culture survey draft 2-5-07.pdf Other-Draft Questionnaire

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Pilot Study of Proposed Medical Office Surveys on Patient Safety	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:

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 %

	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

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.