Information Collection

Pilot Test of the Proposed Workplace Safety Supplemental Item Set For the AHRQ Surveys on Patient Safety Culture™ (SOPS®) Nursing Home Survey

IC 251418 under ICR 202401-0935-006 · OMB 0935-0124.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Pilot Test of the Proposed Workplace Safety Supplemental Item Set For the AHRQ Surveys on Patient Safety Culture™ (SOPS®) Nursing Home Survey	Form and Instruction
1 Attachment B: Draft Workplace Safety Cognitive Interview Attachment B - Draft NH Workplace Safety Cognitive Interview Guide.docx	Form and Instruction
1 Attachment B: Draft Workplace Safety Cognitive Interview Attachment B - Draft NH Workplace Safety Cognitive Interview Guide.docx	Form and Instruction
2 Attachment C: Nursing Home Point of Contact (POC) Instru Attachment C - Nursing Home Point of Contact (POC) Instructions.docx	Form and Instruction
2 Attachment C: Nursing Home Point of Contact (POC) Instru Attachment C - Nursing Home Point of Contact (POC) Instructions.docx	Form and Instruction
3 Attachment A: Draft Workplace Safety Supplemental Item S 04CB6620.DOC.docx	Form and Instruction
3 Attachment A: Draft Workplace Safety Supplemental Item S 04CB6620.DOC.docx	Form and Instruction
Attachment F Nursing Home Background Information Form Attachment F - Nursing Home Background Information Form.docx	Form and Instruction
Attachment F Nursing Home Background Information Form Attachment F - Nursing Home Background Information Form.docx	Form and Instruction
OMB Cover Letter.docx Cover Letter	IC Document
OMB Cover Letter.docx Cover Letter	IC Document
Supporting Statement Part A clean.docx Supporting Statement Part A	IC Document
Supporting Statement Part A clean.docx Supporting Statement Part A	IC Document
Supporting Statement Part B.docx Supporting Statement Part B	IC Document
Supporting Statement Part B.docx Supporting Statement Part B	IC Document
Attachment D - Survey Invitation and Reminder Notices.docx Attachment D: Survey Invitation and Reminder Notices	IC Document
Attachment D - Survey Invitation and Reminder Notices.docx Attachment D: Survey Invitation and Reminder Notices	IC Document
Attachment E.docx Attachment E: Subject Matter Experts and Technical Expert Panel Members	IC Document
Attachment E.docx Attachment E: Subject Matter Experts and Technical Expert Panel Members	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Pilot Test of the Proposed Workplace Safety Supplemental Item Set For the AHRQ Surveys on Patient Safety Cultureâ¢ (SOPSÂ®) Nursing Home Survey

Agency IC Tracking Number:

IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1	Attachment B: Draft Workplace Safety Cognitive Interview Guide	Attachment B - Draft NH Workplace Safety Cognitive Interview Guide.docx	Yes	Yes	Fillable Fileable
Form and Instruction	2	Attachment C: Nursing Home Point of Contact (POC) Instructions	Attachment C - Nursing Home Point of Contact (POC) Instructions.docx	Yes	Yes	Fillable Fileable
Form and Instruction	3	Attachment A: Draft Workplace Safety Supplemental Item Set	04CB6620.DOC.docx	Yes	Yes	Fillable Fileable
Form and Instruction	Attachment F	Nursing Home Background Information Form	Attachment F - Nursing Home Background Information Form.docx	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 4,309

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: 50 %

table that charts list of burden
	Requested	Previously Approved
Annual Number of Responses for this IC	4,309	4,309
Annual IC Time Burden (Hours)	1,432	1,432
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Cover Letter	OMB Cover Letter.docx	02/03/2022
Supporting Statement Part A	Supporting Statement Part A clean.docx	03/11/2022
Supporting Statement Part B	Supporting Statement Part B.docx	02/03/2022
Attachment D: Survey Invitation and Reminder Notices	Attachment D - Survey Invitation and Reminder Notices.docx	02/03/2022
Attachment E: Subject Matter Experts and Technical Expert Panel Members	Attachment E.docx	02/03/2022

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