Information Collection Request

Medical Office Survey on Patient Safety Culture Comparative Database

ICR 202108-0935-001 · OMB 0935-0196 · Historical Active

Forms and Documents

Forms and supporting documents for this ICR
DocumentTypeStatusAvailability
Form Form #4 Example Screen Shots of Web Site Information Collection Form Modified Available
Form Form #4 Data Submission Form Modified Repair queued
Form Form #3 Medical Office Information Form Form Modified Available
Form Form #3 Medical Office Information Form Form Modified Repair queued
Form Form #2 Medical Office SOPS Database Data Use Agreement Form and Instruction Modified Available
Form Form #2 Data Use Agreement Form and Instruction Modified Repair queued
Form Form #1 Medical Office SOPS Database Eligibility Form Form Modified Available
Form Form #1 Eligibility Form Form Modified Repair queued
Supporting Statement Part B -- MOSOPS_Renewal_1-13-21.docx Supporting Statement B Uploaded 2021-08-25 Repair queued
Attachment F - SOPS Databases TEP List.doc Supplementary Document Uploaded 2015-07-27 Repair queued
Attachment G - Example Screenshots.docx Supplementary Document Uploaded 2015-07-27 Repair queued
Attachment E - Medical Office Survey Data File Specifications.pdf Supplementary Document Uploaded 2015-07-27 Repair queued
Attachment D - Medical Office Data Submission Emails_revised 8-5-15.docx Supplementary Document Uploaded 2015-08-21 Repair queued
Supporting Statement Part A -- MOSOPS_Renewal 1-13-21 EC.docx Supporting Statement A Uploaded 2021-09-02 Repair queued

IC Document Collections

Information collection document groups
IC IDCollectionTypeStatusForm
201169 Data Submission Form ModifiedExample Screen Shots of Web Site Information Collection
201169 Data Submission Form Modified
201168 Medical Office Information Form Form ModifiedMedical Office Information Form
201168 Medical Office Information Form Form Modified
201167 Data Use Agreement Form and Instruction ModifiedMedical Office SOPS Database Data Use Agreement
201167 Data Use Agreement Form and Instruction Modified
201166 Eligibility Form Form ModifiedMedical Office SOPS Database Eligibility Form
201166 Eligibility Form Form Modified

ICR Details

Reginfo record details
table that charts list comparision
  Inventory as of this Action Requested Previously Approved
09/30/2024 36 Months From Approved 09/30/2021
3,230 0 2,660
341 0 282
0 0 0





Reginfo record details
4
table that charts list of burden
IC Title Form No. Form Name
Data Submission Form #4
Data Use Agreement Form #2
Eligibility Form Form #1
Medical Office Information Form Form #3

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 3,230 2,660 0 570 0 0
Annual Time Burden (Hours) 341 282 0 59 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0


Reginfo record details
  No