Hospital Information Form

Collection of Information for AHRQ's Hospital Survey on Patient Safety Culture Comparative Database

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Document Name Document Type
Form Form #3 Hospital Information Form Form and Instruction
Form #3 Hospital Information Form Attachment H -- Hospital Information Form.doc Form and Instruction

Information Collection (IC) Details

IC Title:	Hospital Information Form	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
Form and Instruction	Form #3	Hospital Information Form	Attachment H -- Hospital Information 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: 304	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 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	912	162	750
Annual IC Time Burden (Hours)	76	13	63
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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.