Setting Demographics Survey (Appendix A)

TeamSTEPPS® Stakeholder Surveys for AHRQ’s ACTION III Diagnostic Safety Capacity Building Contract Task 3

OMB: 0935-0262

IC ID: 253040

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Setting Demographics Survey (Appendix A)
No New

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction 1 Setting Demographics Survey (Appendix A) Appendix A_TS Dx TAT_1.4.22.docx Yes Yes Fillable Fileable

Health Health Care Services


9 0
Private Sector Businesses or other for-profits, Not-for-profit institutions
   100 %

  Requested 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 9 0 9 0 0 0
Annual IC Time Burden (Hours) 2 0 2 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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