Information Collection Request

Nursing Home Survey on Patient Safety Culture Comparative Database

ICR 201808-0935-002 · OMB 0935-0195 · Historical Active

Forms and Documents

Forms and supporting documents for this ICR
DocumentTypeStatusAvailability
Form Form #1 Eligibility/Registration Form Form and Instruction Modified Available
Form Form #4 NH Welcome and Login Pages Form and Instruction Modified Available
Form Form #3 Nursing Home Site Information Form Form Modified Available
Form Form #2 Data Use Agreement Form and Instruction Modified Available
Attachment G - Example Screenshots of NH SOPS Data Submission Web Site Information Collection.docx Supplementary Document Uploaded 2018-08-20 Available
Attachment E - Nursing Home Data File Specifications.docx Supplementary Document Uploaded 2018-08-20 Available
Supporting Statement Part B_NHSOPS Renewal_4-18-2018 .docx Supporting Statement B Uploaded 2018-08-20 Available
Attachment F - SOPS Databases TEP List.doc Supplementary Document Uploaded 2018-08-20 Available
Supporting Statement Part A 07272008.docx Supporting Statement A Uploaded 2018-09-06 Available

IC Document Collections

Information collection document groups
IC IDCollectionTypeStatusForm
217465 Eligibility/Registration Form Form and Instruction ModifiedEligibility/Registration Form
201035 Data Submission Form and Instruction ModifiedNH Welcome and Login Pages
201034 Nursing Home Site Information Form Form ModifiedNursing Home Site Information Form
201033 Data Use Agreement Form and Instruction ModifiedData Use Agreement

ICR Details

Reginfo record details
table that charts list comparision
  Inventory as of this Action Requested Previously Approved
11/30/2021 36 Months From Approved 11/30/2018
480 0 2,400
91 0 455
0 0 0





Reginfo record details
4
table that charts list of burden
IC Title Form No. Form Name
Data Submission Form #4
Data Use Agreement Form #2
Eligibility/Registration Form Form #1
Nursing Home Site Information Form Form #3

table that charts list of burden
  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 480 2,400 0 -1,920 0 0
Annual Time Burden (Hours) 91 455 0 -364 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0


Reginfo record details
  No