Information Collection

Patient Safety Improvement Initiatives Form

IC 191669 under ICR 201308-0935-001 · OMB 0935-0162.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0935-0162 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Form #3 Patient Safety Improvement Initiatives Form	Form and Instruction
Form #3 Patient Safety Improvement Initiatives Form Attachment A-9 -- Patient Safety Improvement Initiatives Form.doc	Form and Instruction

IC Title:

Patient Safety Improvement Initiatives Form

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Removed

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 and Instruction	Form #3	Patient Safety Improvement Initiatives Form	Attachment A-9 -- Patient Safety Improvement Initiatives Form.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 125

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: 0 %

table that charts list of burden
	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	-375	375
Annual IC Time Burden (Hours)	-31	31
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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