Information Collection Request

Nursing Home Survey on Patient Safety Culture Comparative Database

ICR 201507-0935-001 · OMB 0935-0195 · Historical Active

Forms and Documents

Forms and supporting documents for this ICR
DocumentTypeStatusAvailability
Form Form #1 Eligibility/Registration Form Form and Instruction New Available
Form Form #4 Data Submission Form and Instruction Modified Available
Form Form #3 Nursing Home Site Information Form Form Modified Available
Form Form #2 Data Use Agreement Form and Instruction Modified Available
Form Form #1 Eligibility/Registration Forms Form Removed Available
Attachment G - Example Screenshots of NH SOPS Data Submission Web Site Information Collection.docx Supplementary Document Uploaded 2015-07-15 Repair queued
Attachment E - Nursing Home Data File Specifications.pdf Supplementary Document Uploaded 2015-07-15 Available
201507-0935-001_Supporting Statement Part B -- NHSOPS Comp DB_12-4-14_2015-08-05 Comments_8-7-15 Westat response.doc Supporting Statement B Uploaded 2015-09-01 Available
Attachment F - SOPS Databases TEP list.doc Supplementary Document Uploaded 2015-07-15 Available
201507-0935-001_Supporting Statement Part A -- NHSOPS Comp 08312015.docx Supporting Statement A Uploaded 2015-08-31 Available

IC Document Collections

Information collection document groups
IC IDCollectionTypeStatusForm
217465 Eligibility/Registration Form Form and Instruction New
201035 Data Submission Form and Instruction Modified
201034 Nursing Home Site Information Form Form Modified
201033 Data Use Agreement Form and Instruction Modified
201032 Eligibility/Registration Forms Form Removed

ICR Details

Reginfo record details
table that charts list comparision
  Inventory as of this Action Requested Previously Approved
09/30/2018 36 Months From Approved 06/30/2015
2,400 0 85
455 0 4
0 0 0





table that charts list 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 2,400 85 0 2,315 0 0
Annual Time Burden (Hours) 455 4 0 451 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0


Reginfo record details
  No