Information Collection

Pilot Test of the Proposed Workforce Safety Supplemental Item Set For the Surveys on Patient Safety Culture

IC 243252 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⚠️ Notice: This information collection may be referencing outdated material.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 Workforce Safety Supplemental Item Set For the Surveys on Patient Safety Culture	Form and Instruction
1 Draft Workforce Safety Cognitive Interview Guide Attachment B - Draft Workforce Safety Cognitive Interview Guide_8-3-20.docx	Form and Instruction
2 Attachment C: Hospital Point of Contact (POC) Instructio Attachment C - Hospital Point of Contact (POC) Instructions_8-3-20.docx	Form and Instruction
3 Attachment A: Draft Workforce Safety Supplemental Item Attachment A - Draft Workforce Safety Supplemental Item Set_8-3-20.docx	Form and Instruction
OMB Cover Letter.docx Cover Memo	IC Document
Supporting Statement Part A - Pilot Test of SOPS Workforce Safety_7-28-20 EC.docx Supporting Statement Part A	IC Document
Supporting Statement Part B - Pilot Test of SOPS Workforce Safety 7-28-20.docx Supporting Statement Part B	IC Document
Attachment D - Survey Invitation and Reminder Notices.docx Attachment D: Survey Invitation and Reminder Notices	IC Document
Attachment E - Subject Matter Experts.docx Attachment E: Subject Matter Experts and Technical Expert Panel Members	IC Document

IC Title:

Pilot Test of the Proposed Workforce Safety Supplemental Item Set For the Surveys 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	Draft Workforce Safety Cognitive Interview Guide	Attachment B - Draft Workforce Safety Cognitive Interview Guide_8-3-20.docx	Yes	Yes	Fillable Fileable
Form and Instruction	2	Attachment C: Hospital Point of Contact (POC) Instructions	Attachment C - Hospital Point of Contact (POC) Instructions_8-3-20.docx	Yes	Yes	Fillable Fileable
Form and Instruction	3	Attachment A: Draft Workforce Safety Supplemental Item	Attachment A - Draft Workforce Safety Supplemental Item Set_8-3-20.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 5,782

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	5,782	5,782
Annual IC Time Burden (Hours)	1,935	1,935
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Cover Memo	OMB Cover Letter.docx	08/19/2020
Supporting Statement Part A	Supporting Statement Part A - Pilot Test of SOPS Workforce Safety_7-28-20 EC.docx	08/19/2020
Supporting Statement Part B	Supporting Statement Part B - Pilot Test of SOPS Workforce Safety 7-28-20.docx	08/19/2020
Attachment D: Survey Invitation and Reminder Notices	Attachment D - Survey Invitation and Reminder Notices.docx	08/19/2020
Attachment E: Subject Matter Experts and Technical Expert Panel Members	Attachment E - Subject Matter Experts.docx	08/19/2020

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