Information Collection

57.106 Patient Safety Monthly Reporting Plan

IC 7134 under ICR 201211-0920-005 · 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⚠️ Notice: This information collection may be referencing outdated material.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

Document Name Document Type
57.106_PSReportPlan_BLANK.doc Other-WORD
14. Reporting Plan (IC# 1).pdf Att G14 RP IC Document

Information Collection (IC) Details

View Information Collection (IC)

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:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-WORD			57.106_PSReportPlan_BLANK.doc		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 10,000	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	10,000	-44,000	54,000
Annual IC Time Burden (Hours)	70,000	38,500	31,500
Annual IC Cost Burden (Dollars)	2,705,500	2,543,500	162,000

Documents for IC

Title	Document	Date Uploaded
Att G14 RP	14. Reporting Plan (IC# 1).pdf	10/15/2012

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.