Identifying, Assessing, and Balancing Competing Risks of Multiple Hospital-Acquired Conditions (HACs)

Questionnaire and Data Collection Testing, Evaluation, and Research for the Agency for Healthcare Research and Quality

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Document Name Document Type
Form 2 Identifying, Assessing, and Balancing Competing Risks of Multiple Hospital-Acquired Conditions (HACs) Form and Instruction
2 Attachment B – HAC Risk Dashboard Tool Low-Fidelity Prot Attachment B withboxes2.docx Form and Instruction
Clearance Form B.docx Clearance Form B IC Document
OMB Cover Letter (Form B).doc Cover Letter (Form B) IC Document

Information Collection (IC) Details

IC Title:	Identifying, Assessing, and Balancing Competing Risks of Multiple Hospital-Acquired Conditions (HACs)	Agency IC Tracking Number:

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	2	Attachment B – HAC Risk Dashboard Tool Low-Fidelity Prototype Evaluation Focus Group Guide	Attachment B withboxes2.docx		No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 24	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	24	24
Annual IC Time Burden (Hours)	36	36
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Clearance Form B	Clearance Form B.docx	04/14/2017
Cover Letter (Form B)	OMB Cover Letter (Form B).doc	04/14/2017

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