Information Collection

Validation Pilot For The Ahrq Patient Safety Indicators Phase Ii

IC 185563 under ICR 200801-0935-001 · OMB 0935-0124.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0935-0124 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Form #1 VALIDATION PILOT FOR THE AHRQ PATIENT SAFETY INDICATORS PHASE II	Form and Instruction
Form #1 Interest form Attachment H -- Phase II Interest Form.doc	Form and Instruction
Form #3 Foreign body left during procedure abstraction tool Attachment C -- Foreign body Left During Procedure Abstraction Tool.doc	Form
Form #2 Participant survey Attachment B1 -- Phase II Participant Survey.doc	Form and Instruction
Form #4 Postoperative hemorrhage or hematoma abstraction tool Attachment D -- Postoperative Hemorrhage or Hematoma Abstraction Tool.doc	Form
Form #5 Postoperative physiologic & metabolic derangement abstra Attachment E -- Postoperative Physiologic & Metabolic Derangement Abstraction Tool.doc	Form
Form #6 Postoperative respiratory failure abstraction tool Attachment F -- Postoperative Respiratory Failure Abstraction Tool.doc	Form
Form #7 Postoperative wound dehiscence abstraction tool Attachment G -- Postoperative Wound Dehiscence Abstraction Tool.doc	Form
Supporting Statement Part A -- Phase II PSI Validation 6-27-2008.doc Supporting Statement Part A -- Phase II PSI Validation 6-27-2008	IC Document
Supporting Statement Part B -- Phase II PSI Validation 6-19-2008.doc Supporting Statement Part B -- Phase II PSI Validation 6-19-2008	IC Document
Attachment I -- Training manual.doc Attachment I -- Training manual	IC Document
Attachment B -- Phase I Participant Survey.doc Attachment B -- Phase I Participant Survey	IC Document
Attachment C1--Instructions for foreign body left during procedure abstraction tool.doc Attachment C1--Instructions for foreign body left during procedure abstraction tool	IC Document
Attachment D1 -- Instructions for postoperative hemorrhage or hematoma abstraction tool.doc Attachment D1 -- Instructions for postoperative hemorrhage or hematoma abstraction tool	IC Document
Attachment E1 -- Instructions for postoperative physiologic & metabolic derangement abstraction.doc Attachment E1 -- Instructions for postoperative physiologic & metabolic derangement abstraction	IC Document
Attachment F1 -- Instructions for postoperative respiratory failure abstraction tool.doc Attachment F1 -- Instructions for postoperative respiratory failure abstraction tool	IC Document
Attachment G1 -- Instructions for postoperative wound dehiscence abstraction tool.doc Attachment G1 -- Instructions for postoperative wound dehiscence abstraction tool	IC Document
memocoverletter.doc memocoverletter	IC Document
PSI validation pilot dcl.doc Revised Supporting Statement Part A	IC Document
pasback.doc AHRQ memo 11-10-08	IC Document
terms of clearance.doc terms of clearance: PSI pilot phase II	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

VALIDATION PILOT FOR THE AHRQ PATIENT SAFETY INDICATORS PHASE II

Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	Form #1	Interest form	Attachment H -- Phase II Interest Form.doc	Yes	Yes	Fillable Fileable
Form	Form #3	Foreign body left during procedure abstraction tool	Attachment C -- Foreign body Left During Procedure Abstraction Tool.doc	No	No	Paper Only
Form and Instruction	Form #2	Participant survey	Attachment B1 -- Phase II Participant Survey.doc	No	No	Paper Only
Form	Form #4	Postoperative hemorrhage or hematoma abstraction tool	Attachment D -- Postoperative Hemorrhage or Hematoma Abstraction Tool.doc	No	No	Paper Only
Form	Form #5	Postoperative physiologic & metabolic derangement abstraction tool	Attachment E -- Postoperative Physiologic & Metabolic Derangement Abstraction Tool.doc	No	No	Paper Only
Form	Form #6	Postoperative respiratory failure abstraction tool	Attachment F -- Postoperative Respiratory Failure Abstraction Tool.doc	No	No	Paper Only
Form	Form #7	Postoperative wound dehiscence abstraction tool	Attachment G -- Postoperative Wound Dehiscence Abstraction Tool.doc	No	No	Paper Only

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 320

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to New Statute	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA	Previously Approved
Annual Number of Responses for this IC	2,700	0	0	0	0	0
Annual IC Time Burden (Hours)	2,845	0	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Supporting Statement Part A -- Phase II PSI Validation 6-27-2008	Supporting Statement Part A -- Phase II PSI Validation 6-27-2008.doc	06/27/2008
Supporting Statement Part B -- Phase II PSI Validation 6-19-2008	Supporting Statement Part B -- Phase II PSI Validation 6-19-2008.doc	06/27/2008
Attachment I -- Training manual	Attachment I -- Training manual.doc	06/27/2008
Attachment B -- Phase I Participant Survey	Attachment B -- Phase I Participant Survey.doc	06/27/2008
Attachment C1--Instructions for foreign body left during procedure abstraction tool	Attachment C1--Instructions for foreign body left during procedure abstraction tool.doc	06/27/2008
Attachment D1 -- Instructions for postoperative hemorrhage or hematoma abstraction tool	Attachment D1 -- Instructions for postoperative hemorrhage or hematoma abstraction tool.doc	06/27/2008
Attachment E1 -- Instructions for postoperative physiologic & metabolic derangement abstraction	Attachment E1 -- Instructions for postoperative physiologic & metabolic derangement abstraction.doc	06/27/2008
Attachment F1 -- Instructions for postoperative respiratory failure abstraction tool	Attachment F1 -- Instructions for postoperative respiratory failure abstraction tool.doc	06/27/2008
Attachment G1 -- Instructions for postoperative wound dehiscence abstraction tool	Attachment G1 -- Instructions for postoperative wound dehiscence abstraction tool.doc	06/27/2008
memocoverletter	memocoverletter.doc	06/27/2008
Revised Supporting Statement Part A	PSI validation pilot dcl.doc	11/17/2008
AHRQ memo 11-10-08	pasback.doc	11/17/2008
terms of clearance: PSI pilot phase II	terms of clearance.doc	11/17/2008

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.