3 Attachment D: Hospital Information Submission Form

Child Hospital Consumer Assessment of Healthcare Providers and Systems (Child HCAHPS) Survey Database

Attachment D Hospital Information Submission Form_updated 7-15-19_

OMB: 0935-0243

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Hospital Information Submission Form




Please provide the following information. The information you provide for data submission purposes will be kept confidential.



Hospital Name

Hospital Bed Size

State

Vendor Email

Sample Hospital

100

MD

[email protected]


Shape1

Public reporting burden for this collection of information is estimated to average 5 minutes per response, the estimated time required to complete the form. 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, Rockville, MD 20857.


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AuthorTeresa Dodson
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File Created2022-10-17

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