Medical Office Information Form

Medical Office Survey on Patient Safety Culture Comparative Database

OMB: 0935-0196

IC ID: 201168

Information Collection (IC) Details

View Information Collection (IC)

Medical Office Information Form
 
No Modified
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form Form #3 Medical Office Information Form Attachment C - Medical Office Site Information Form.docx Yes Yes Fillable Fileable

Health Immunization Management

 

85 0
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   100 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 2,975 0 525 0 0 2,450
Annual IC Time Burden (Hours) 248 0 44 0 0 204
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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

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