Information Collection

Department of Defense (DoD) Patient Safety Culture Survey

IC 5614 under ICR 200911-0720-005 · OMB 0720-0034.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0720-0034 can be found here:

Documents and Forms

Document Name Document Type
DoD Patient Safety Survey.doc Other-Survey

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Department of Defense (DoD) Patient Safety Culture Survey	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 32 CFR 199

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Survey			DoD Patient Safety Survey.doc		Yes	Yes	Fillable Fileable

Line of Business: Defense and National Security

Subfunction: Operational Defense

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 14,022	Number of Respondents for Small Entity: 0

Affected Public: Federal Government

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	14,022	14,022
Annual IC Time Burden (Hours)	2,384	2,384
Annual IC Cost Burden (Dollars)	0	0

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.