Information Collection

57.150 Patient Safety Component -- Annual Facility Survey for LTAC

IC 200381 under ICR 202112-0920-014 · OMB 0920-0666.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0666 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 57.150 LTAC Annual 57.150 Patient Safety Component -- Annual Facility Survey for LTAC	Form
57.150 LTAC Annual 57.150_ LTAC Annual Facility Survey_BLANK 2021 57.150_ LTAC Annual Facility Survey_BLANK 2021.pdf	Form
57.150 TOI 57 150_LTAC Survey_2021 TOI_57_150_LTAC_Survey_2021[1].docx	Form and Instruction
19. Sepsis.pdf Att G19_Sepsis	IC Document
19. Sepsis.pdf Att G19_Sepsis	IC Document

IC Title:

57.150 Patient Safety Component -- Annual Facility Survey for LTAC

Agency IC Tracking Number:

0920-0666

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	57.150	TOI 57 150_LTAC Survey_2021	TOI_57_150_LTAC_Survey_2021[1].docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 620

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	620	0	620
Annual IC Time Burden (Hours)	847	744	103
Annual IC Cost Burden (Dollars)	24,589	0	24,589

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Att G19_Sepsis	19. Sepsis.pdf	09/26/2018

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