Information Collection

Department of Defense (DoD) Patient Safety Culture Survey

IC 5614 under ICR 202106-0720-002 · OMB 0720-0034.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0720-0034 can be found here:

Documents and Forms

Document Name Document Type
PSafety Questionnaire _ 3.28.2018.docx Other-Questionnaire
PSafety Questionnaire _ 3.28.2018.docx Other-Questionnaire
Patient Safety Intro Screenshot_March 2018.docx Instruction
Patient Safety Intro Screenshot_March 2018.docx Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Department of Defense (DoD) Patient Safety Culture Survey	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Removed

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
Other-Questionnaire			PSafety Questionnaire _ 3.28.2018.docx		Yes	Yes	Fillable Fileable
Instruction			Patient Safety Intro Screenshot_March 2018.docx		Yes	Yes	Fillable Fileable

Line of Business: Defense and National Security

Subfunction: Operational Defense

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 9,200	Number of Respondents for Small Entity: 0

Affected Public: Federal Government

Percentage of Respondents Reporting Electronically: 100 %

	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	-9,200	9,200
Annual IC Time Burden (Hours)	-1,533	1,533
Annual IC Cost Burden (Dollars)	-64,599	64,599

Documents for IC

Title	Document	Date Uploaded
No associated records found

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