Information Collection

Patient Safety Monthly Reporting Plan

IC 7134 under ICR 200712-0920-003 · OMB 0920-0666.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0666 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 57.75A Patient Safety Monthly Reporting Plan	Form
57.75A Patient Safety Monthly Reporting Plan A_PSPlan.ppt	Form

IC Title:

Patient Safety Monthly Reporting Plan

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

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
Form	57.75A	Patient Safety Monthly Reporting Plan	A_PSPlan.ppt		Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,500

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	174,395	0	174,395
Annual IC Time Burden (Hours)	65,817	0	65,817
Annual IC Cost Burden (Dollars)	39,600	-39,560,400	39,600,000

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.