Form #3 Nursing Home Site Information Form

Nursing Home Survey on Patient Safety Culture Comparative Database

Attachment C - Nursing Home Site Information Form

OMB: 0935-0195

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




Attachment C: Nursing Home Site Information Form


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Response options for Who Administered to:

  • All staff/Sample of staff

  • Selected departments/units only (please specify)

  • Selected staff positions only (please specify)

  • Selected departments/units and selected staff positions (please specify)


Response options for Survey Mode:

  • Paper

  • Web

  • Mixed mode (paper & web)

  • Other


Response options for control/operation:

  • For profit

  • Non profit

  • Government


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Public reporting burden for this collection of information is estimated to average 5 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, 5600 Fishers Lane, # 7, Rockville, MD 20857.




File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorSuzanne Streagle
File Modified0000-00-00
File Created2021-11-01

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