Information Collection

Attachment B – Safety culture survey_Data collection instrument

IC 227743 under ICR 202009-0935-001 · OMB 0935-0239.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Attachment B – Safety culture survey_Data collection instrument	Form and Instruction
Form 1 Attachment B – Safety culture survey_Data collection instrument Attachment B – Safety culture survey_Data collection instrument	Form and Instruction
1 Attachment B – Safety culture survey_Data collection ins Attachment B_Safety culture survey_Data collection instrument_20170727.docx	Form and Instruction
1 Attachment B – Safety culture survey_Data collection ins Attachment B_Safety culture survey_Data collection clean.docx	Form and Instruction
Attachment A_Safety culture survey_Cover letter and reminder notice_20170727.docx Attachment A – Safety culture survey_Cover letter and reminder notice	IC Document
Attachment A_Safety culture survey_Cover letter and reminder notice_20170727.docx Attachment A – Safety culture survey_Cover letter and reminder notice	IC Document

IC Title:

Attachment B â Safety culture survey_Data collection instrument

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1	Attachment B â Safety culture survey_Data collection instrument	Attachment B_Safety culture survey_Data collection clean.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,000

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 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	1,000	-11,000	12,000
Annual IC Time Burden (Hours)	250	-2,750	3,000
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment A â Safety culture survey_Cover letter and reminder notice	Attachment A_Safety culture survey_Cover letter and reminder notice_20170727.docx	07/28/2017

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