Form #1 Form #1 Eligibility/Registration Forms

Nursing Home Survey on Patient Safety Culture Comparative Database

Attachment B - NH Eligibility and Regis Forms

Eligibility/Registration Forms

OMB: 0935-0195

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A

Form Approved
OMB No. 0935-XXXX
Exp. Date XX/XX/20XX

ttachment B: Nursing Home Eligibility and Registration Forms



Public reporting burden for this collection of information is estimated to average 3 minutes per response, the estimated time required to complete the survey. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-XXXX) AHRQ, 540 Gaither Road, Room # 5036, Rockville, MD 20850.






Attachment B: Nursing Home Eligibility and Registration Forms (continued)




File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorSuzanne Streagle
File Modified0000-00-00
File Created2021-01-31

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