Information Collection

57.106 Patient Safety Monthly Reporting Plan

IC 7134 under ICR 201112-0920-004 · 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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
Document Name	Document Type
F1.3PSC_MonthlyReportingPlan.pdf	Other-PDF
57.106 Patient Safety Monthly Reporting Plan 57.106_PSReportPlan_BLANK.ppt	Form

IC Title:

57.106 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:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-PDF			F1.3PSC_MonthlyReportingPlan.pdf		Yes	Yes	Fillable Printable
Form	57.106	Patient Safety Monthly Reporting Plan	57.106_PSReportPlan_BLANK.ppt		Yes	Yes	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 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	54,000	54,000
Annual IC Time Burden (Hours)	31,500	31,500
Annual IC Cost Burden (Dollars)	162,000	162,000

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.