Readiness and Implementation assessment

AHRQ Safety Program for Improving Surgical Care and Recovery

Documents and Forms

Document Name Document Type
Form 3 Readiness and Implementation assessment Form and Instruction
3 Readiness assessment Attachment F_Readiness Assessment_Data collection instrument_20170727.docx Form and Instruction
3 Readiness assessment Attachment F_Readiness Assessment_Data clean.docx Form and Instruction
4 Implementation assessment Attachment H_Implementation assessment_Data collection instrument_20170727.docx Form and Instruction
4 Implementation assessment Attachment H_Implementation assessment_Data clean.docx Form and Instruction
Attachment E_Readiness assessment_Cover letter and reminder notice_20170727.docx Attachment E – Readiness assessment_Cover letter and reminder notice IC Document
Attachment E_Readiness assessment_Cover letter and reminder notice_20170727.docx Attachment E – Readiness assessment_Cover letter and reminder notice IC Document
Attachment G_Implementation assessment_Cover letter and reminder notice_20170727.docx Attachment G – Implementation assessment_Cover letter and reminder notice IC Document
Attachment G_Implementation assessment_Cover letter and reminder notice_20170727.docx Attachment G – Implementation assessment_Cover letter and reminder notice IC Document

Information Collection (IC) Details

IC Title:	Readiness and Implementation assessment	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 and Instruction	3	Readiness assessment	Attachment F_Readiness Assessment_Data clean.docx		No		Fillable Fileable
Form and Instruction	4	Implementation assessment	Attachment H_Implementation assessment_Data clean.docx		No		Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 684	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: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	684	-36	720
Annual IC Time Burden (Hours)	684	-36	720
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Attachment E – Readiness assessment_Cover letter and reminder notice	Attachment E_Readiness assessment_Cover letter and reminder notice_20170727.docx	07/28/2017
Attachment G – Implementation assessment_Cover letter and reminder notice	Attachment G_Implementation assessment_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.