Information Collection

Pilot test and bridge study

IC 218086 under ICR 201508-0935-001 · OMB 0935-0230.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 3 Crosswalk Between the Original AHRQ Hospital Survey on Patient Safety Culture and Draft Version 2.0 Pilot test and bridge study	Form and Instruction
Form 4 Draft Health IT Patient Safety Pilot test and bridge study	Form and Instruction
3 Crosswalk Between the Original AHRQ Hospital Survey on P Attachment A - Crosswalk of Hospital Survey on Patient Saafety 9-2-15.docx	Form and Instruction
4 Draft Health IT Patient Safety Attachment B - Draft Health IT and Patient Safety Supplemental Items and Composites 9-2-15 (3).docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	3				Yes	Yes	Fillable Fileable
Form and Instruction	4				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 9,188

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: 90 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	9,188	9,188
Annual IC Time Burden (Hours)	2,297	2,297
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.

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