Adverse Event Reporting Follow-up Survey

National Study of the Hospital Adverse Event Reporting Survey

Documents and Forms

Document Name Document Type
Form Form #1 Adverse Event Reporting Follow-up Survey Form and Instruction
Form #1 Questionnaire -- Mailed Version Attachment A -- Risk Manager Questionnaire -- Mail Version.doc Form and Instruction
Form #2 Questionnaire -- Telephone Version Attachment B -- Risk Manager Questionnaire -- Phone Version.doc Form and Instruction
Attachment C -- Questionnaire Cover Letter.doc Attachment C -- Questionnaire Cover Letter IC Document
Attachment D -- Reminder Post Card.doc Attachment D -- Reminder Post Card IC Document
Attachment E -- Remail Cover Letter.doc Attachment E -- Remail Cover Letter IC Document
Attachment F -- Phone Survey Intro Script.doc Attachment F -- Phone Survey Intro Script IC Document

Information Collection (IC) Details

IC Title:	Adverse Event Reporting Follow-up Survey	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	Form #1	Questionnaire -- Mailed Version	Attachment A -- Risk Manager Questionnaire -- Mail Version.doc		No	No	Paper Only
Form and Instruction	Form #2	Questionnaire -- Telephone Version	Attachment B -- Risk Manager Questionnaire -- Phone Version.doc		No	No	Paper Only

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,020	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions, 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	1,020	1,020
Annual IC Time Burden (Hours)	425	425
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Attachment C -- Questionnaire Cover Letter	Attachment C -- Questionnaire Cover Letter.doc	10/06/2008
Attachment D -- Reminder Post Card	Attachment D -- Reminder Post Card.doc	10/06/2008
Attachment E -- Remail Cover Letter	Attachment E -- Remail Cover Letter.doc	10/06/2008
Attachment F -- Phone Survey Intro Script	Attachment F -- Phone Survey Intro Script.doc	10/06/2008

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