Information Collection Request

The AHRQ Safety Program for Methicillin-Resistant Staphylococcus aureus (MRSA) Prevention

ICR 202107-0935-003 · OMB 0935-0260 · Historical Active

Forms and Documents

Forms and supporting documents for this ICR
DocumentTypeStatusAvailability
Form 11 Attachment L: Clinical Outcomes Data for LTC Form and Instruction New Available
Form 11 Attachment L: Clinical Outcomes Data for LTC Form and Instruction New Repair queued
Form 10 Attachment K: Clinical Outcomes Data for Surgical Services Form and Instruction New Available
Form 10 Attachment K: Clinical Outcomes Data for Surgical Services Form and Instruction New Repair queued
Form 9 Attachment J: Clinical Outcomes Data for ICU/Non-ICU Form and Instruction New Available
Form 9 Attachment J: Clinical Outcomes Data for ICU/Non-ICU Form and Instruction New Repair queued
Form 11 Attachment L: Clinical Outcomes Data for LTC Form and Instruction New Available
Form 11 Attachment L: Clinical Outcomes Data for LTC Form and Instruction New Repair queued
Form 10 Attachment K: Clinical Outcomes Data for Surgical Services Form and Instruction New Available
Form 10 Attachment K: Clinical Outcomes Data for Surgical Services Form and Instruction New Repair queued
Form 9 Attachment J: Clinical Outcomes Data for ICU/Non-ICU Form and Instruction New Available
Form 9 Attachment J: Clinical Outcomes Data for ICU/Non-ICU Form and Instruction New Repair queued
Form 9 Attachment J: Clinical Outcomes Data for ICU/Non-ICU Form and Instruction New Available
Form 9 Attachment J: Clinical Outcomes Data for ICU/Non-ICU Form and Instruction New Repair queued
Form 9 Attachment J: Clinical Outcomes Data for ICU/Non-ICU Form and Instruction New Available
Form 9 Attachment J: Clinical Outcomes Data for ICU/Non-ICU Form and Instruction New Repair queued
Form 8 Attachment G: LTC Team Checkup Tool Form and Instruction New Available
Form 8 TEAM CHECK-UP TOOL – Long-Term Care (LTC) Form and Instruction New Repair queued
Form 7 Attachment F: Surgical Services Team Checkup Tool Form and Instruction New Available
Form 6 Attachment E: ICU/Non-ICU Team Checkup Tool Form and Instruction New Available
Form 6 Team Checkup Tool Form and Instruction New Repair queued
Form 5 Attachment D: LTC Gap Analysis Form and Instruction New Available
Form 4 Attachment C: Surgical Services Gap Analysis Form and Instruction New Available
Form 3 Attachment B: ICU/Non-ICU Gap Analysis Form and Instruction New Available
Form 3 Gap Analysis Form and Instruction New Repair queued
Form 2 2,500 Form and Instruction New Available
Form 2 Attachment I: Survey of Patient Safety Culture – NHSOPS Form and Instruction New Available
Form 1 Attachment H: Survey of Patient Safety Culture – HSOPS Form and Instruction New Available
Form 1 Attachment H: Survey of Patient Safety Culture – HSOPS Form and Instruction New Available
Supporting Statement A eb rev_21.07.23.mam.docx Supporting Statement A Uploaded 2021-07-26 Available
Supporting Statement B.docx Supporting Statement B Uploaded 2021-07-23 Repair queued
Att P Schedule of Evaluation Activities.docx Supplementary Document Uploaded 2021-07-23 Repair queued
Att O Completion Guide for LTC Clinical Outcomes Data.docx Supplementary Document Uploaded 2021-07-23 Repair queued
Att N Completion Guide for Surgical Services Clinical Outcomes Data.docx Supplementary Document Uploaded 2021-07-23 Repair queued
Att M Completion Guide for ICU-Non-ICU Clinical Outcomes Data.docx Supplementary Document Uploaded 2021-07-23 Repair queued

IC Document Collections

Information collection document groups
IC IDCollectionTypeStatusForm
248521 Attachment L: Clinical Outcomes Data for LTC Form and Instruction NewAttachment L: Clinical Outcomes Data for LTC
248521 Attachment L: Clinical Outcomes Data for LTC Form and Instruction New
248520 Attachment K: Clinical Outcomes Data for Surgical Services Form and Instruction NewAttachment K: Clinical Outcomes Data for Surgical Services
248520 Attachment K: Clinical Outcomes Data for Surgical Services Form and Instruction New
248519 Attachment J: Clinical Outcomes Data for ICU/Non-ICU Form and Instruction NewAttachment J: Clinical Outcomes Data for ICU/Non-ICU
248519 Attachment J: Clinical Outcomes Data for ICU/Non-ICU Form and Instruction New
248518 Attachment L: Clinical Outcomes Data for LTC Form and Instruction NewAttachment L: Clinical Outcomes Data for LTC
248518 Attachment L: Clinical Outcomes Data for LTC Form and Instruction New
248517 Attachment K: Clinical Outcomes Data for Surgical Services Form and Instruction NewAttachment K: Clinical Outcomes Data for Surgical Services
248517 Attachment K: Clinical Outcomes Data for Surgical Services Form and Instruction New
248516 Attachment J: Clinical Outcomes Data for ICU/Non-ICU Form and Instruction NewAttachment J: Clinical Outcomes Data for ICU/Non-ICU
248516 Attachment J: Clinical Outcomes Data for ICU/Non-ICU Form and Instruction New
248515 Attachment J: Clinical Outcomes Data for ICU/Non-ICU Form and Instruction NewAttachment J: Clinical Outcomes Data for ICU/Non-ICU
248515 Attachment J: Clinical Outcomes Data for ICU/Non-ICU Form and Instruction New
248507 Attachment J: Clinical Outcomes Data for ICU/Non-ICU Form and Instruction NewAttachment J: Clinical Outcomes Data for ICU/Non-ICU
248507 Attachment J: Clinical Outcomes Data for ICU/Non-ICU Form and Instruction New
248495 TEAM CHECK-UP TOOL – Long-Term Care (LTC) Form and Instruction NewAttachment G: LTC Team Checkup Tool
248495 TEAM CHECK-UP TOOL – Long-Term Care (LTC) Form and Instruction New
248492 Team Checkup Tool Form and Instruction NewAttachment F: Surgical Services Team Checkup Tool
248492 Team Checkup Tool Form and Instruction NewAttachment E: ICU/Non-ICU Team Checkup Tool
248492 Team Checkup Tool Form and Instruction New
248491 Gap Analysis Form and Instruction NewAttachment D: LTC Gap Analysis
248491 Gap Analysis Form and Instruction NewAttachment C: Surgical Services Gap Analysis
248491 Gap Analysis Form and Instruction NewAttachment B: ICU/Non-ICU Gap Analysis
248491 Gap Analysis Form and Instruction New
248489 Attachment I: Survey of Patient Safety Culture – NHSOPS Form and Instruction New2,500
248489 Attachment I: Survey of Patient Safety Culture – NHSOPS Form and Instruction New
248486 Attachment H: Survey of Patient Safety Culture – HSOPS Form and Instruction NewAttachment H: Survey of Patient Safety Culture – HSOPS
248486 Attachment H: Survey of Patient Safety Culture – HSOPS Form and Instruction New

ICR Details

Reginfo record details
table that charts list comparision
  Inventory as of this Action Requested Previously Approved
08/31/2024 36 Months From Approved
36,637 0 0
11,552 0 0
0 0 0





Reginfo record details
13
table that charts list of burden
IC Title Form No. Form Name
Attachment H: Survey of Patient Safety Culture – HSOPS 1
Attachment I: Survey of Patient Safety Culture – NHSOPS 2
Attachment J: Clinical Outcomes Data for ICU/Non-ICU 9
Attachment J: Clinical Outcomes Data for ICU/Non-ICU 9
Attachment J: Clinical Outcomes Data for ICU/Non-ICU 9
Attachment J: Clinical Outcomes Data for ICU/Non-ICU 9
Attachment K: Clinical Outcomes Data for Surgical Services 10
Attachment K: Clinical Outcomes Data for Surgical Services 10
Attachment L: Clinical Outcomes Data for LTC 11
Attachment L: Clinical Outcomes Data for LTC 11
Gap Analysis 3, 4, 5 ,   ,  
TEAM CHECK-UP TOOL – Long-Term Care (LTC) 8
Team Checkup Tool 6, 7 ,  

table that charts list of burden
  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 36,637 0 0 36,637 0 0
Annual Time Burden (Hours) 11,552 0 0 11,552 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0


Reginfo record details
  No