Pretest for the Ambulatory Surgery SOPS

Pretest of the Ambulatory Surgery/Procedure Survey on Patient Safety Culture

Documents and Forms

Document Name Document Type
Form Form # 2 Pretest for the Ambulatory Surgery SOPS Form and Instruction
Form # 2 Ambulatory Surgery SOPS Attachment B - Ambulatory Surgery SOPS.docx Form and Instruction
Attachment D - Pretest Cover Letter and Reminder Notice for Survey.docx Attachment D - Pretest Cover Letter and Reminder Notice for Survey IC Document

Information Collection (IC) Details

IC Title:	Pretest for the Ambulatory Surgery SOPS	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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 # 2	Ambulatory Surgery SOPS	Attachment B - Ambulatory Surgery SOPS.docx		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 529	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
Annual Number of Responses for this IC	529	529
Annual IC Time Burden (Hours)	132	132
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Attachment D - Pretest Cover Letter and Reminder Notice for Survey	Attachment D - Pretest Cover Letter and Reminder Notice for Survey.docx	09/27/2013

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