Information Collection

Pilot Test of the Proposed Diagnostic Safety Supplemental Item Set for the Medical Office Survey on Patient Safety Culture

IC 235839 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⚠️ Notice: This information collection may be referencing outdated material.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 Pilot Test of the Proposed Diagnostic Safety Supplemental Item Set for the Medical Office Survey on Patient Safety Culture	Form and Instruction
1 Attachment B: Draft Diagnostic Safety Cognitive Intervie Attachment B - Diagnostic Safety Cog Interview Guide 3-26-19.docx	Form and Instruction
2 Medical office information survey Attachment C - Medical office information form_site-level data file specs.docx	Form and Instruction
3 Pilot test Attachment A - Draft Diagnostic Safety Supplemental Item Set 3-13-19.docx	Form and Instruction
4 Attachment A - Draft Diagnostic Safety Supplemental Item Attachment A - Draft Diagnostic Safety Supplemental Item Set 7-3-19.docx	Form and Instruction
5 Attachment B - Diagnostic Safety Cog Interview Guide 7-3 Attachment B - Diagnostic Safety Cog Interview Guide 7-3-19.docx	Form and Instruction
OMB Cover Letter.docx.doc Cover Letter	IC Document
Attachment C 1 - Medical Office Point of Contact (POC) Instructions 3-13-19.docx Attachment C1: Medical Office Point of Contact (POC) Instructions	IC Document
Attachment D - Survey Invitation and Reminder Notices 3-13-19.docx Attachment D: Survey Invitation and Reminder Notices	IC Document
Attachment E -- 60 Day FRN.pdf Attachment E: Federal Register Notice	IC Document
Attachment F - Diagnostic Safety TEP List 3-13-19.docx Attachment F: Technical Expert Panel Members	IC Document
Supporting Statement Part A - Pilot Test of SOPS Dx Safety - 4-9-2019 (003).docx Supporting Statement A	IC Document
Supporting Statement Part B - Pilot Test of SOPS Dx Safety - 3-26-2019.docx Supporting Statement Part B	IC Document
Supporting Statement Part A - Pilot Test of SOPS Dx Safety - 7-18-2019.docx Supporting Statement A	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Pilot Test of the Proposed Diagnostic Safety Supplemental Item Set for the Medical Office Survey on Patient Safety Culture

Agency IC Tracking Number:

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1	Attachment B: Draft Diagnostic Safety Cognitive Interview Guide	Attachment B - Diagnostic Safety Cog Interview Guide 3-26-19.docx	Yes	Yes	Fillable Fileable
Form and Instruction	2	Medical office information survey	Attachment C - Medical office information form_site-level data file specs.docx	Yes	Yes	Fillable Fileable
Form and Instruction	3	Pilot test	Attachment A - Draft Diagnostic Safety Supplemental Item Set 3-13-19.docx	Yes	Yes	Fillable Fileable
Form and Instruction	4	Attachment A - Draft Diagnostic Safety Supplemental Item Set 7-3-19.docx	Attachment A - Draft Diagnostic Safety Supplemental Item Set 7-3-19.docx	Yes	Yes	Fillable Fileable
Form and Instruction	5	Attachment B - Diagnostic Safety Cog Interview Guide 7-3-19.docx	Attachment B - Diagnostic Safety Cog Interview Guide 7-3-19.docx	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,545

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: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,545	1,545
Annual IC Time Burden (Hours)	538	538
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Cover Letter	OMB Cover Letter.docx.doc	05/03/2019
Attachment C1: Medical Office Point of Contact (POC) Instructions	Attachment C 1 - Medical Office Point of Contact (POC) Instructions 3-13-19.docx	05/03/2019
Attachment D: Survey Invitation and Reminder Notices	Attachment D - Survey Invitation and Reminder Notices 3-13-19.docx	05/03/2019
Attachment E: Federal Register Notice	Attachment E -- 60 Day FRN.pdf	05/03/2019
Attachment F: Technical Expert Panel Members	Attachment F - Diagnostic Safety TEP List 3-13-19.docx	05/03/2019
Supporting Statement A	Supporting Statement Part A - Pilot Test of SOPS Dx Safety - 4-9-2019 (003).docx	05/03/2019
Supporting Statement Part B	Supporting Statement Part B - Pilot Test of SOPS Dx Safety - 3-26-2019.docx	05/03/2019
Supporting Statement A	Supporting Statement Part A - Pilot Test of SOPS Dx Safety - 7-18-2019.docx	08/07/2019

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