Form #1 Form #1 Medical Office SOPS Database Eligibility Form

Medical Office Survey on Patient Safety Culture Comparative Database

Attachment A - Medical Office Eligibility and Registration Form

Eligibility Form

OMB: 0935-0196

Document [docx]
Download: docx | pdf

AHRQ Medical Office Survey on Patient Safety Culture Database, Supporting Statement A

Shape8

Form Approved
OMB No. 0935-XXXX
Exp. Date XX/XX/20XX



Attachment A: Medical Office Eligibility and Registration Form




Shape1

Shape2

*4. How many medical offices will you be submitting for?


Shape3

*5. Did you administer the SOPS Value and Efficiency Supplemental Item Set with your SOPS Medical Office Survey?







Shape7 Shape6 Shape5 Shape4

*2. Will you have completed survey data collection and be able to submit your final electronic data file by October 20, 2021?

*5. Did you administer the SOPS Value and Efficiency Supplemental Item Set with your SOPS Medical Office Survey?

*4. How many medical offices will you be submitting for?

Public reporting burden for this collection of information is estimated to average 3 minutes per response, the estimated time required to complete the survey. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-XXXX) AHRQ, 540 Gaither Road, Room # 5036, Rockville, MD 20850.












File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorSuzanne Streagle
File Modified0000-00-00
File Created2021-09-08

© 2024 OMB.report | Privacy Policy