Information Collection

57.106 Patient Safety Monthly Reporting Plan

IC 7134 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⚠️ Notice: This information collection may be referencing outdated material.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 57.106 Patient Saf 57.106 Patient Safety Monthly Reporting Plan	Form and Instruction
57.106 Patient Saf 57.106_PSReportPlan.2021 57.106_PSReportPlan.2021.pdf	Form and Instruction
57.106 57.106_PS ReportPlan_BLANK 57.106_PS_ReportPlan_BLANK[1].docx	Form and Instruction

IC Title:

57.106 Patient Safety Monthly Reporting Plan

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	57.106	57.106_PS ReportPlan_BLANK	57.106_PS_ReportPlan_BLANK[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: 7,821

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	Previously Approved
Annual Number of Responses for this IC	93,852	93,852
Annual IC Time Burden (Hours)	23,463	23,463
Annual IC Cost Burden (Dollars)	930,543	930,543

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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