Building Diagnostic Safety Capacity - Diagnostic Safety Measurement Resource Evaluation Plan

Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery

Documents and Forms

Document Name Document Type
Form 1 Building Diagnostic Safety Capacity - Diagnostic Safety Measurement Resource Evaluation Plan Form and Instruction
1 Appendix A: Organizational Characteristics Survey Appendix A_Organizational Characteristics Survey.docx Form and Instruction
1 Appendix A: Organizational Characteristics Survey Appendix A_Organizational Characteristics Survey.docx Form and Instruction
2 Appendix B: Organizational Readiness for Implementation Appendix B_ORIC.docx Form and Instruction
2 Appendix B: Organizational Readiness for Implementation Appendix B_ORIC.docx Form and Instruction
3 Appendix C: Pre-Test Interview Protocol Appendix C_Pre-test Interview Protocol.docx Form and Instruction
3 Appendix C: Pre-Test Interview Protocol Appendix C_Pre-test Interview Protocol.docx Form and Instruction
3 Appendix D: Post-test Evaluation Interview Protocol Appendix D_Post-test Interview Protocol.docx Form and Instruction
3 Appendix D: Post-test Evaluation Interview Protocol Appendix D_Post-test Interview Protocol.docx Form and Instruction
OMB Cover Letter.docx Cover Letter IC Document
OMB Cover Letter.docx Cover Letter IC Document
Supporting Statement A_Operational Measurement_final ms.docx Supporting Statement IC Document
Supporting Statement A_Operational Measurement_final ms.docx Supporting Statement IC Document

Information Collection (IC) Details

IC Title:	Building Diagnostic Safety Capacity - Diagnostic Safety Measurement Resource Evaluation Plan	Agency IC Tracking Number:

IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Electronic Capability
Form and Instruction	1	Appendix A: Organizational Characteristics Survey	Appendix A_Organizational Characteristics Survey.docx	No	Paper Only
Form and Instruction	2	Appendix B: Organizational Readiness for Implementation Change (ORIC)	Appendix B_ORIC.docx	No	Paper Only
Form and Instruction	3	Appendix C: Pre-Test Interview Protocol	Appendix C_Pre-test Interview Protocol.docx	No	Paper Only
Form and Instruction	3	Appendix D: Post-test Evaluation Interview Protocol	Appendix D_Post-test Interview Protocol.docx	No	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 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: 0 %

	Requested	Previously Approved
Annual Number of Responses for this IC	160	160
Annual IC Time Burden (Hours)	155	155
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Cover Letter	OMB Cover Letter.docx	01/13/2021
Supporting Statement	Supporting Statement A_Operational Measurement_final ms.docx	01/13/2021

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