Information Collection

57.151 Patient Safety Component -- Annual Facility Survey for IRF

IC 200382 under ICR 202310-0920-013 · 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⚠️ Notice: This information collection may be referencing outdated material.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

Document Name Document Type
Form 57.151 57.151 Patient Safety Component -- Annual Facility Survey for IRF Form and Instruction
57.151 Patient Safety Component—Annual Facility Survey for IRF 57.151 REHAB Annual Facility Survey-Clean Version.docx Form and Instruction
57.151 Patient Safety Component—Annual Facility Survey for IRF 57.151 REHAB Annual Facility Survey-Clean Version.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	57.151 Patient Safety Component -- Annual Facility Survey for IRF	Agency IC Tracking Number:	0920-0666

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	57.151	Patient Safety ComponentâAnnual Facility Survey for IRF	57.151 REHAB Annual Facility Survey-Clean Version.docx	NA	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,160	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 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	1,160	-180	1,340
Annual IC Time Burden (Hours)	1,721	-110	1,831
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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.