Information Collection

Patient Safety Confidentiality Complaint Form

IC 186804 under ICR 200904-0935-001 · OMB 0935-0143.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0935-0143 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Form #1 Patient Safety Confidentiality Complaint Form	Form and Instruction
Form #1 Patient Safety Confidentiality Complaint Form Attachment H -- Patient Safety Confidentiality Complaint Form.doc	Form and Instruction

IC Title:

Patient Safety Confidentiality Complaint Form

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 and Instruction	Form #1	Patient Safety Confidentiality Complaint Form	Attachment H -- Patient Safety Confidentiality Complaint Form.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 50

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	Previously Approved
Annual Number of Responses for this IC	50	50
Annual IC Time Burden (Hours)	17	17
Annual IC Cost Burden (Dollars)	0	0

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.