Attachment J – Data collection instrument: Site Visit Assessment

AHRQ Safety Program for Improving Surgical Care and Recovery

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Document Name Document Type
Form 5 Attachment J – Data collection instrument: Site Visit Assessment Form and Instruction
5 Site visits Attachment J_Site visit Assessment_Data collection instrument_20170727.docx Form and Instruction
Attachment I_Site visit assessment_Cover letter and reminder notice_20170727.docx Attachment I – Site visit assessment_Cover letter and reminder notice.docx IC Document

Information Collection (IC) Details

IC Title:	Attachment J – Data collection instrument: Site Visit Assessment	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	5	Site visits	Attachment J_Site visit Assessment_Data collection instrument_20170727.docx		No		Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 40	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	40	40
Annual IC Time Burden (Hours)	320	320
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Attachment I – Site visit assessment_Cover letter and reminder notice.docx	Attachment I_Site visit assessment_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.