Information Collection

57.103 Patient Safety Component - Annual Hospital Survey

IC 183572 under ICR 201308-0920-010 · 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⚠️ Notice: This information collection may be referencing outdated material.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
Form 57.103 57.103 Patient Safety Component - Annual Hospital Survey	Form
57.103 Patient Safety - Annual Hospital Survey 57.103_PSHospSurv_BLANK.DOCX	Form
14. Patient Safety Monthly Reporting Plan.pdf Patient Safety - Reporting Plan	IC Document

IC Title:

57.103 Patient Safety Component - Annual Hospital Survey

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
Form	57.103	Patient Safety - Annual Hospital Survey	57.103_PSHospSurv_BLANK.DOCX		Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

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: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	6,000	0	6,000
Annual IC Time Burden (Hours)	3,000	0	3,000
Annual IC Cost Burden (Dollars)	113,520	113,520	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Patient Safety - Reporting Plan	14. Patient Safety Monthly Reporting Plan.pdf	08/21/2013

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