Information Collection

Environmental Scan for Guide to Improving Patient Safety in Primary Care Settings by Engaging Patients and Families

IC 219183 under ICR 201409-0935-002 · OMB 0935-0124.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0935-0124 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 2 Environmental Scan for Guide to Improving Patient Safety in Primary Care Settings by Engaging Patients and Families	Form and Instruction
2 Attachment B: Key Informant Interview Guide- In-person Attachment B Interview Guides_InPerson20151113docx.docx	Form and Instruction
4 Attachment D: Interview Guide for Case Study Development Attachment D Interview Guides_Case Study_In Person 20151113docx.docx	Form and Instruction
6 Attachment F: Interview Guide for Patients/Family Member Attachment F PatientsFamilyInterview Guide_In_Person 20151113.docx	Form and Instruction
8 Attachment H: Interview Guide for Primary Care Practice Attachment H Interview Guide PCP StaffPhysicians_Telephone 20151113.docx	Form and Instruction
1 Attachment A: Key Informant Interview Guide- Telephone Attachment A Interview Guides_Telephone 20151113docx.docx	Form and Instruction
3 Attachment C: Interview Guide for Case Study Development Attachment C Interview Guides_Telephone 20151113docx.docx	Form and Instruction
5 Attachment E: Interview Guide for Patients/Family Member Attachment E PatientsFamilyInterview Guide_Telephone 20151113.docx	Form and Instruction
7 Attachment G: Interview Guide for Primary Care Practice Attachment G Interview Guide PCP StaffPhysicians_Telephone 20151113.docx	Form and Instruction
TO3 OMB Cover Letter 20151030 Draft.doc Cover Letter	IC Document
Clearance Form 20151120.docx Supporting Statement	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Environmental Scan for Guide to Improving Patient Safety in Primary Care Settings by Engaging Patients and Families

Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Electronic Capability
Form and Instruction	2	Attachment B: Key Informant Interview Guide- In-person	Attachment B Interview Guides_InPerson20151113docx.docx	No	Fillable Fileable
Form and Instruction	4	Attachment D: Interview Guide for Case Study Development- In-person	Attachment D Interview Guides_Case Study_In Person 20151113docx.docx	No	Fillable Fileable
Form and Instruction	6	Attachment F: Interview Guide for Patients/Family Members/Caregivers- In-person	Attachment F PatientsFamilyInterview Guide_In_Person 20151113.docx	No	Fillable Fileable
Form and Instruction	8	Attachment H: Interview Guide for Primary Care Practice Staff and Physicians- In-person	Attachment H Interview Guide PCP StaffPhysicians_Telephone 20151113.docx	No	Fillable Fileable
Form and Instruction	1	Attachment A: Key Informant Interview Guide- Telephone	Attachment A Interview Guides_Telephone 20151113docx.docx	No	Fillable Fileable
Form and Instruction	3	Attachment C: Interview Guide for Case Study Development- Telephone	Attachment C Interview Guides_Telephone 20151113docx.docx	No	Fillable Fileable
Form and Instruction	5	Attachment E: Interview Guide for Patients/Family Members/Caregivers- Telephone	Attachment E PatientsFamilyInterview Guide_Telephone 20151113.docx	No	Fillable Fileable
Form and Instruction	7	Attachment G: Interview Guide for Primary Care Practice Staff and Physicians- Telephone	Attachment G Interview Guide PCP StaffPhysicians_Telephone 20151113.docx	No	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 48

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
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	48	48
Annual IC Time Burden (Hours)	43	43
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Cover Letter	TO3 OMB Cover Letter 20151030 Draft.doc	12/04/2015
Supporting Statement	Clearance Form 20151120.docx	12/04/2015

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