Safety event intake form and follow up

A PROTOTYPE CONSUMER REPORTING SYSTEM FOR PATIENT SAFETY EVENTS

OMB: 0935-0214

IC ID: 207255

Information Collection (IC) Details

View Information Collection (IC)

Safety event intake form and follow up
 
No New
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction Form #1 Intake reporting form - web version Attachment B -- Intake Reporting Form - Web Version.doc Yes Yes Fillable Fileable
Form and Instruction Form #2 Intake reporting form - phone version Attachment D -- Intake Reporting Form -- Phone Version.doc Yes Yes Fillable Fileable
Form and Instruction Form #3 Intake reporting form follow up Attachment E -- Intake Reporting Form Follow Up.doc Yes Yes Fillable Fileable

Health Immunization Management

 

840 0
   
Individuals or Households
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 840 0 840 0 0 0
Annual IC Time Burden (Hours) 490 0 490 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Attachment A -- Introductory Pages of Website Attachment A -- Introductory Pages of Website.docx 06/06/2013
Attachment C -- FAQs List Attachment C -- FAQs List.docx 06/06/2013
Attachment F -- Marketing Flyer Attachment F -- Marketing Flyer.pdf 06/06/2013
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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