Form # 3 Form # 3 Attachment C: Hospital Site Information Form

Collection of Information for AHRQ's Hospital Survey on Patient Safety Culture Comparative Database

Attachment C - Hospital Site Information Form

Hospital Information Form

OMB: 0935-0162

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AHRQ Hospital Survey on Patient Safety Culture Database, Supporting Statement A

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Form Approved
OMB No. 0935-XXXX
Exp. Date XX/XX/20XX




Attachment C: Hospital Site Information Form


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Public reporting burden for this collection of information is estimated to average 3 minutes per response, the estimated time required to complete the survey. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-XXXX) AHRQ, 5600 Fishers Lane, Rockville, MD 20857.



Dropdown options for bed size:

Ownership and control:

Teaching status:

To whom the survey was administered:

Survey mode:





Number of times administered:


File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorWillow Burns
File Modified0000-00-00
File Created2021-01-16

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