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Federal forms, ICRs, and supporting documents

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Validation Pilot For The Ahrq Patient Safety Indicators Phase Ii

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

Documents and Forms
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Form and Instruction
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Form and Instruction
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IC Document
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VALIDATION PILOT FOR THE AHRQ PATIENT SAFETY INDICATORS PHASE II
 
New
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL 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

Health Consumer Health and Safety

 

320 0
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   0 %

  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

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.