Eligibility/Registration Form

Nursing Home Survey on Patient Safety Culture Comparative Database

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0935-0195 can be found here:

Documents and Forms

Document Name Document Type
Form Form #1 Eligibility/Registration Form Form and Instruction
Form #1 Eligibility/Registration Form Attachment A - Nursing Home Eligibility and Registration Form_revised 8-25-15 (2).docx Form and Instruction

Information Collection (IC) Details

IC Title:	Eligibility/Registration Form	Agency IC Tracking Number:

Is this a Common Form? No		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	Form #1	Eligibility/Registration Form	Attachment A - Nursing Home Eligibility and Registration Form_revised 8-25-15 (2).docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 300	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	300	300
Annual IC Time Burden (Hours)	15	15
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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