Department of Defense (DoD) Patient Safety Culture Survey

ICR 201507-0720-003

OMB: 0720-0034

Federal Form Document

Forms and Documents
Document
Name
Status
Supplementary Document
2015-07-16
Supporting Statement B
2015-09-21
Supporting Statement A
2015-09-21
IC Document Collections
ICR Details
0720-0034 201507-0720-003
Historical Active 200911-0720-005
DOD/DODOASHA
Department of Defense (DoD) Patient Safety Culture Survey
Reinstatement without change of a previously approved collection   No
Regular
Approved without change 09/30/2015
Retrieve Notice of Action (NOA) 08/10/2015
  Inventory as of this Action Requested Previously Approved
09/30/2018 36 Months From Approved
14,022 0 0
2,337 0 0
64,641 0 0

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.

None
None

Not associated with rulemaking

  79 FR 32237 06/04/2014
80 FR 44942 07/28/2015
No

1
IC Title Form No. Form Name
Department of Defense (DoD) Patient Safety Culture Survey

  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
No
Yes
Miscellaneous Actions
New cost information was put into ROCIS as part of the amendment.

$270,349
Yes Part B of Supporting Statement
No
No
No
No
Uncollected
Frederick Licari 571 372-0493 [email protected]

  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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
08/10/2015


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