Department of Defense (DoD) Patient Safety Culture Survey

Forms and Documents

Document Name	Status
Prescribing Document NDAA 2001 0720-0034, 7.16.2015.PDF Supplementary Document	2015-07-16
Supporting Statement Part B 0720-0034_2015-0921.doc Supporting Statement B	2015-09-21
Supporting Statement Part A 0720-0034_2015-0921.doc Supporting Statement A	2015-09-21

IC Document Collections

IC ID	Document Title	Status
5614	Department of Defense (DoD) Patient Safety Culture Survey Other-Survey	Modified

ICR Details

OMB Control No: 0720-0034	ICR Reference No: 201507-0720-003
Status: Historical Active	Previous ICR Reference No: 200911-0720-005
Agency/Subagency: DOD/DODOASHA	Agency Tracking No:
Title: Department of Defense (DoD) Patient Safety Culture Survey
Type of Information Collection: Reinstatement without change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 09/30/2015
	Date Received in OIRA: 08/10/2015
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2018	36 Months From Approved
Responses	14,022	0	0
Time Burden (Hours)	2,337	0	0
Cost Burden (Dollars)	64,641	0	0

---

Abstract: Anonymous web based survey to gather information from DoD Military Healthy System (MHS) personnel on their opinions of patient safety in their MHS operational environment to fulfill Congressionally-mandated DoD Patient Safety Program.

---

Authorizing Statute(s): None

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 32237	06/04/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 44942	07/28/2015
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Department of Defense (DoD) Patient Safety Culture Survey

---

ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	14,022	0	0	0	0	14,022
Annual Time Burden (Hours)	2,337	0	0	-47	0	2,384
Annual Cost Burden (Dollars)	64,641	0	0	64,641	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: New cost information was put into ROCIS as part of the amendment.

---

Annual Cost to Federal Government: $270,349

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  No

---

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 08/10/2015

---