Information Collection Request

Nursing Home Survey on Patient Safety Culture Comparative Database

ICR 202109-0935-002 · OMB 0935-0195 · Received in OIRA

Forms and Documents

Forms and supporting documents for this ICR
DocumentTypeStatusAvailability
Form Form #1 Eligibility/Registration Form Form and Instruction Modified Missing upstream
Form Form #4 Data Submission Form and Instruction Modified Repair queued
Form Form #3 Nursing Home Site Information Form Form Modified Repair queued
Form Form #2 Data Use Agreement Form and Instruction Modified Repair queued
Attachment G - Example Screenshots of NH SOPS Data Submission Web Site Information Collection.docx Supplementary Document Uploaded 2021-09-15 Missing upstream
Attachment E - Nursing Home Data File Specifications.docx Supplementary Document Uploaded 2021-09-15 Repair queued
Attachment B - Nursing Home Data Use Agreement.docx Supporting Statement B Uploaded 2021-09-15 Missing upstream
Attachment F - SOPS Databases TEP List.docx Supplementary Document Uploaded 2021-09-15 Repair queued
Supporting Statement Part A_NHSOPS Renewal_4-28-21.docx Supporting Statement A Uploaded 2021-09-21 Repair queued

IC Document Collections

Information collection document groups
IC IDCollectionTypeStatusForm
217465 Eligibility/Registration Form Form and Instruction Modified
201035 Data Submission Form and Instruction Modified
201034 Nursing Home Site Information Form Form Modified
201033 Data Use Agreement Form and Instruction Modified

ICR Details

Reginfo record details
table that charts list comparision
  Requested Previously Approved
36 Months From Approved 11/30/2021
320 480
61 91
0 0





Reginfo record details
4
table that charts list of burden
IC Title Form No. Form Name
Data Submission Form #4 NH Welcome and Login Pages
Data Use Agreement Form #2 Data Use Agreement
Eligibility/Registration Form Form #1 Eligibility/Registration Form
Nursing Home Site Information Form Form #3 Nursing Home Site Information Form

table that charts list of burden
  Total Request 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 320 480 0 -160 0 0
Annual Time Burden (Hours) 61 91 0 -30 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0


Reginfo record details
  No