Attachment C – Draft HSOPS 2.0 Cognitive Interview Guide

Pilot Test of the Proposed Hospital Survey on Patient Safety Culture Version 2.0

Documents and Forms

Document Name Document Type
Form 1 Attachment C – Draft HSOPS 2.0 Cognitive Interview Guide Form and Instruction
1 Draft HSOPS 2.0 Cognitive Interview Guide Attachment C - HSOPS 2 0 Cog Interview Guide 3-20-15.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Attachment C – Draft HSOPS 2.0 Cognitive Interview Guide	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	1	Draft HSOPS 2.0 Cognitive Interview Guide	Attachment C - HSOPS 2 0 Cog Interview Guide 3-20-15.docx		No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 36	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: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	36	36
Annual IC Time Burden (Hours)	54	54
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.