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⚠️ Notice: This information collection may be referencing outdated material.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 3 Identifying, Assessing, and Balancing Competing Risks of Multiple Hospital-Acquired Conditions (HACs) Form and Instruction
3 Attachment C – HAC Risk Dashboard Tool Key Informant Int Attachment C withboxes2.docx Form and Instruction
Clearance Form C.docx Clearance Form (C) IC Document
OMB Cover Letter (Form C ).doc Cover Letter (Form C ) 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	3	Attachment C – HAC Risk Dashboard Tool Key Informant Interview Guide	Attachment C withboxes2.docx		No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 28	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	28	28
Annual IC Time Burden (Hours)	28	28
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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

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