Information Collection

57.103 Patient Safety Component - Annual Hospital Survey

IC 183572 under ICR 202006-0920-003 · OMB 0920-0666.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0666 can be found here:

Documents and Forms

Document Name Document Type
Form CDC 57.103 57.103 Patient Safety Component - Annual Hospital Survey Form
CDC 57.103 Annual Hospital Survey - Patient Safety Component 57.103_Annual Facility Survey_BLANK.docx Form
21. Surveys - Hospital, LTAC, & IRF.pdf Att G21_Surveys--Hospital, LTAC, IRF, and Dialysis IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	57.103 Patient Safety Component - Annual Hospital Survey	Agency IC Tracking Number:	0920-0666

Is this a Common Form? No		IC Status: Unchanged

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	CDC 57.103	Annual Hospital Survey - Patient Safety Component	57.103_Annual Facility Survey_BLANK.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 5,175	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	5,175	5,175
Annual IC Time Burden (Hours)	6,469	6,469
Annual IC Cost Burden (Dollars)	205,240	205,240

Documents for IC

Title	Document	Date Uploaded
Att G21_Surveys--Hospital, LTAC, IRF, and Dialysis	21. Surveys - Hospital, LTAC, & IRF.pdf	09/26/2018

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