Information Collection Request

Development of the Guide to Patient and Family Engagement in Health Care Quality and Safety in the Hospital Setting

ICR 201102-0935-002 · OMB 0935-0176 · Historical Active

Forms and Documents

Forms and supporting documents for this ICR
DocumentTypeStatusAvailability
Form Form #11 Patient Survey Form and Instruction New Available
Form Form #10 Staff Survey Form and Instruction New Available
Form Form #9 Focus Group with Patients & Family Protocol Form and Instruction New Available
Form Form #8 Focus Group with Patients' Family Protocol Form and Instruction New Available
Form Form #7 Focus Group with Patients Protocol Form and Instruction New Available
Form Form #6 Bi-Weekly Semi-Structured Interview Protocol Form and Instruction New Available
Form Form #5 Collection of Documentation Protocol Form and Instruction New Available
Form Form #4 Semi-Structured Staff Interview Post-Implementation Protocol Form and Instruction New Available
Form Form #3 Semi-Structured Staff Interview Pre-Implementation Protocol Form and Instruction New Available
Form Form #2 Semi-Structured Leader Interview Post-Implementation Protocol Form and Instruction New Available
Form Form #1 Semi-Structured Leader Interview Pre-Implementation Protocol Form and Instruction New Available
IRB DETERMINATION FORM_02434 007 (Task 7)_4 12 11.pdf Supplementary Document Uploaded 2011-04-18 Available
Attachment K -- Observation Protocol_040911.doc Supplementary Document Uploaded 2011-04-18 Available
Supporting Statement Part B -- Evaluation of the Guide to PFE 4-18-2011.doc Supporting Statement B Uploaded 2011-04-18 Available
Attachment D -- Component 3_materials.pdf Supplementary Document Uploaded 2011-02-10 Available
Attachment C -- Component 2_materials.pdf Supplementary Document Uploaded 2011-02-10 Available
Attachment B -- Component 1_Materials.pdf Supplementary Document Uploaded 2011-02-10 Available
Attachment A -- Healthcare Research and Quality Act of 1999.pdf Supplementary Document Uploaded 2011-02-10 Available
Attachment R -- Invitation to Participate in Patient Survey 020411.doc Supplementary Document Uploaded 2011-02-10 Available
Attachment P -- Invitation to Participate in Staff Survey 020411.doc Supplementary Document Uploaded 2011-02-10 Available
Supporting Statement Part A -- Evaluation of the Guide to PFE 4-18-2011.doc Supporting Statement A Uploaded 2011-04-18 Available

IC Document Collections

Information collection document groups
IC IDCollectionTypeStatusForm
196396 Patient survey Form and Instruction NewPatient Survey
196395 Staff survey Form and Instruction NewStaff Survey
196394 Focus group with patients & family Form and Instruction NewFocus Group with Patients & Family Protocol
196393 Focus group with patients' family Form and Instruction NewFocus Group with Patients' Family Protocol
196392 Focus group with patients Form and Instruction NewFocus Group with Patients Protocol
196391 Bi-weekly semi-structured interviews Form and Instruction NewBi-Weekly Semi-Structured Interview Protocol
196390 Collection of documentation Form and Instruction NewCollection of Documentation Protocol
196389 Semi-structured staff interviews - post-implementation Form and Instruction NewSemi-Structured Staff Interview Post-Implementation Protocol
196388 Semi-structured staff interviews - pre-implementation Form and Instruction NewSemi-Structured Staff Interview Pre-Implementation Protocol
196387 Semi-structured leader interviews - post-implementation Form and Instruction NewSemi-Structured Leader Interview Post-Implementation Protocol
196386 Semi-structured leader interviews - pre-implementation Form and Instruction NewSemi-Structured Leader Interview Pre-Implementation Protocol

ICR Details

Reginfo record details
table that charts list comparision
  Inventory as of this Action Requested Previously Approved
04/30/2013 24 Months From Approved
2,272 0 0
1,190 0 0
0 0 0





Reginfo record details
11
table that charts list of burden
IC Title Form No. Form Name
Bi-weekly semi-structured interviews Form #6
Collection of documentation Form #5
Focus group with patients Form #7
Focus group with patients & family Form #9
Focus group with patients' family Form #8
Patient survey Form #11
Semi-structured leader interviews - post-implementation Form #2
Semi-structured leader interviews - pre-implementation Form #1
Semi-structured staff interviews - post-implementation Form #4
Semi-structured staff interviews - pre-implementation Form #3
Staff survey Form #10

table that charts list of burden
  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 2,272 0 0 2,272 0 0
Annual Time Burden (Hours) 1,190 0 0 1,190 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0


Reginfo record details
  No