Information Collection

Patient Safety Monthly Reporting Plan

IC 7134 under ICR 200901-0920-009 · 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⚠️ Notice: This information collection may be referencing outdated material.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

Document Name Document Type
Form 57.75A Patient Safety Monthly Reporting Plan Form
57.75A A_PSPlan.ppt A_PSPlan.ppt Form

Information Collection (IC) Details

View Information Collection (IC)

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:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	57.75A	A_PSPlan.ppt	A_PSPlan.ppt		No	No	Fillable Printable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 6,000	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	54,000	40,500	13,500
Annual IC Time Burden (Hours)	31,500	23,625	7,875
Annual IC Cost Burden (Dollars)	162,000	121,500	40,500

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.