Information Collection

Identifying, Assessing, and Balancing Competing Risks of Multiple Hospital-Acquired Conditions (HACs)

IC 226350 under ICR 201708-0935-002 · OMB 0935-0124.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0935-0124 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Identifying, Assessing, and Balancing Competing Risks of Multiple Hospital-Acquired Conditions (HACs)	Form and Instruction
1 Attachment A – HAC Risk Dashboard Tool Information Needs Attachment A withboxes.docx	Form and Instruction
Clearance Form A.docx Clearance Form A	IC Document
OMB Cover Letter (Form A).doc Cover Letter (Form A)	IC Document

IC Title:

Identifying, Assessing, and Balancing Competing Risks of Multiple Hospital-Acquired Conditions (HACs)

Agency IC Tracking Number:

IC Status: Removed

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 A â HAC Risk Dashboard Tool Information Needs Identification Focus Group Guide	Attachment A withboxes.docx		No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 24

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	-24	24
Annual IC Time Burden (Hours)	-36	36
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Clearance Form A	Clearance Form A.docx	04/14/2017
Cover Letter (Form A)	OMB Cover Letter (Form A).doc	04/14/2017

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