Information Collection

Attachment B – Safety culture survey_Data collection instrument

IC 227743 under ICR 201707-0935-004 · OMB 0935-0239.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0935-0239 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Attachment B – Safety culture survey_Data collection instrument	Form and Instruction
1 Attachment B – Safety culture survey_Data collection ins Attachment B_Safety culture survey_Data collection instrument_20170727.docx	Form and Instruction
Attachment A_Safety culture survey_Cover letter and reminder notice_20170727.docx Attachment A – Safety culture survey_Cover letter and reminder notice	IC Document

IC Title:

Attachment B â Safety culture survey_Data collection instrument

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	1	Attachment B â Safety culture survey_Data collection instrument	Attachment B_Safety culture survey_Data collection instrument_20170727.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 12,000

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

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

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	12,000	12,000
Annual IC Time Burden (Hours)	3,000	3,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment A â Safety culture survey_Cover letter and reminder notice	Attachment A_Safety culture survey_Cover letter and reminder notice_20170727.docx	07/28/2017

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