Data Submission

Medical Office Survey on Patient Safety Culture Comparative Database

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0935-0196 can be found here:

Documents and Forms

Document Name Document Type
Form Form #4 Data Submission Form
Form #4 Example Screen Shots of Web Site Information Collection Attachment E - Medical Office Survey Data File Specifications.pdf Form
Attachment F - SOPS Databases TEP List.doc Attachment F: Databases TEP List IC Document
Attachment D - Medical Office Data Submission Emails.docx Attachment D: Data Submission Emails IC Document
Attachment G - Example Screenshots of MO SOPS Data Submission Web Site Information Collection.docx Attachment G: Example Screen Shots of Medical Office Survey on Patient Safety Culture Data Submission Web Site Information Colle IC Document
60 Day FRN.pdf Federal Register Notice IC Document

Information Collection (IC) Details

IC Title:	Data Submission	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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	Form #4	Example Screen Shots of Web Site Information Collection	Attachment E - Medical Office Survey Data File Specifications.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 70	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 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	70	-80	150
Annual IC Time Burden (Hours)	70	-80	150
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Attachment F: Databases TEP List	Attachment F - SOPS Databases TEP List.doc	07/25/2018
Attachment D: Data Submission Emails	Attachment D - Medical Office Data Submission Emails.docx	07/25/2018
Attachment G: Example Screen Shots of Medical Office Survey on Patient Safety Culture Data Submission Web Site Information Collection	Attachment G - Example Screenshots of MO SOPS Data Submission Web Site Information Collection.docx	07/25/2018
Federal Register Notice	60 Day FRN.pdf	07/25/2018

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