Information Collection

57.103 Patient Safety Component - Annual Hospital Survey

IC 183572 under ICR 201508-0920-001 · OMB 0920-0666.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0666 can be found here:

Documents and Forms

Document Name Document Type
Form CDC 57.103 57.103 Patient Safety Component - Annual Hospital Survey Form
CDC 57.103 Patient Safety Component-Annual Hospital Survey 57.103_Annual Hospital Survey.DOCX Form
Att G18_Surveys - Hospital, LTAC, IRF, and Dialysis.pdf Att G18_Surveys--Hospital, LTAC, IRF, and Dialysis IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	57.103 Patient Safety Component - Annual Hospital Survey	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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	CDC 57.103	Patient Safety Component-Annual Hospital Survey	57.103_Annual Hospital Survey.DOCX		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 5,000	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	5,000	-1,000	6,000
Annual IC Time Burden (Hours)	4,167	-833	5,000
Annual IC Cost Burden (Dollars)	94,600	-18,920	113,520

Documents for IC

Title	Document	Date Uploaded
Att G18_Surveys--Hospital, LTAC, IRF, and Dialysis	Att G18_Surveys - Hospital, LTAC, IRF, and Dialysis.pdf	09/09/2015

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