Nursing Home Survey on Patient Safety Culture Comparative Database

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form Form #4 Data Submission	Form and Instruction	New	Available
Form Form #3 Nursing Home Site Information Form	Form	New	Available
Form Form #2 Data Use Agreement	Form and Instruction	New	Available
Form Form #1 Eligibility/Registration Forms	Form	New	Available
Supporting Statement Part B -- NHSOPS Comparative Database 5-15-2012.doc	Supporting Statement B	Uploaded 2012-05-29	Available
Attachment H - TEP lists 8-16-11.doc	Supplementary Document	Uploaded 2012-01-31	Available
Attachment G - Expert reviewers.docx	Supplementary Document	Uploaded 2012-01-31	Available
Attachment A - NH SOPS questionnaire.doc	Supplementary Document	Uploaded 2012-01-31	Available
Attachment F -- Federal Register Notice.pdf	Supplementary Document	Uploaded 2012-01-31	Available
Attachment E - Sample Indiv NH Feedback Rpt.docx	Supplementary Document	Uploaded 2012-01-31	Available
Attachment M - NH SOPS Data Submission Specs.pdf	Supplementary Document	Uploaded 2012-01-31	Available
Attachment L - NH Questionnaire Upload Page.docx	Supplementary Document	Uploaded 2012-01-31	Available
Attachment I - Emails - NH SOPS Data Submission.doc	Supplementary Document	Uploaded 2012-01-31	Available
Attachment K - NH Submission Home Page.docx	Supplementary Document	Uploaded 2012-01-31	Available
Supporting Statement Part A -- NHSOPS Comparative Database 5-15-2012.doc	Supporting Statement A	Uploaded 2012-05-29	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
201035	Data Submission	Form and Instruction	New
201034	Nursing Home Site Information Form	Form	New
201033	Data Use Agreement	Form and Instruction	New
201032	Eligibility/Registration Forms	Form	New

ICR Details

OMB Control No: 0935-0195	ICR Reference No: 201202-0935-003
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/AHRQ	Agency Tracking No:
Title: Nursing Home Survey on Patient Safety Culture Comparative Database
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 06/08/2012
	Date Received in OIRA: 02/07/2012
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2015	36 Months From Approved
Responses	680	0	0
Time Burden (Hours)	511	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The Agency for Healthcare Research and Quality (AHRQ) requests that the Office of Management and Budget (OMB) approve, under the Paperwork Reduction Act of 1995, AHRQ's collection of information for the AHRQ Nursing Home Survey on Patient Safety Culture (Nursing Home SOPS) Comparative Database. The Nursing Home SOPS Comparative Database consists of data from the AHRQ Nursing Home Survey on Patient Safety Culture. Nursing homes in the U.S. are asked to voluntarily submit data from the survey to AHRQ through its contractor, Westat. The Nursing Home SOPS Database is modeled after the Hospital SOPS Database [OMB NO. 0935-0162, approved 05/04/2010] that was originally developed by AHRQ in 2006 in response to requests from hospitals interested in knowing how their patient safety culture survey results compare to those of other hospitals.

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Authorizing Statute(s): US Code: 42 USC 299 Name of Law: Healthcare Research and Quality Act of 1999
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 67732	11/02/2011
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 4038	01/26/2012
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 4

table that charts list of burden

IC Title	Form No.	Form Name
Eligibility/Registration Forms	Form #1	Eligibility/Registration Forms
Data Use Agreement	Form #2	Data Use Agreement
Nursing Home Site Information Form	Form #3	Nursing Home Site Information Form
Data Submission	Form #4	NH Welcome and Login Pages

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ICR Summary of Burden

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	680	0	0	680	0	0
Annual Time Burden (Hours)	511	0	0	511	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This is a new Information Collection Request.

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Annual Cost to Federal Government: $310,000

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 02/07/2012

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