Implementation and Testing of Diagnostic Safety Resources

ICR 202406-0935-001

OMB:

Federal Form Document

Forms and Documents

Document Name	Status
Form 20 20. Attachment V - Patient Interview Protocol Form and Instruction	New
Form 19 19. Attachment U - Patient Toolkit Survey - Patient Form and Instruction	New
Form 18 18. Attachment T - Provider Interview Protocol Form and Instruction	New
Form 17 17. Attachment S - Patient Toolkit Survey-Provider Form and Instruction	New
Form 16 16. Attachment R - Provider Characteristics Form Form and Instruction	New
Form 15 15. Attachment Q - Clinical Self-Efficacy Survey Form and Instruction	New
Form 14 14. Attachment P - Calibrate Dx Survey Form and Instruction	New
Form 13a 13. Omnibus Safety and Culture Survey Form and Instruction	New
Form 12 12. Attachment M - Diagnostic Safety Event Report Form and Instruction	New
Form 11 11. Attachment L - Measure Dx Declaration of Measurement Strategy Form and Instruction	New
Form 10 10. Attachment K - Measure Dx Organizational Self-Assessment Form and Instruction	New
Form 9 9. Attachment J - Implementation Interviews Protocol Form and Instruction	New
Form 8 8. Attachment I - Clinical Sustainability Assessment Tool (CSAT) Form and Instruction	New
Form 7 7. Attachment H - Post-Technical Assistance Evaluation Form Form and Instruction	New
Form 6 6. Attachment G - Post-training Evaluation Form Form and Instruction	New
Form 5a 5. Diagnostic Safety Supplemental Set Form and Instruction	New
Form 4 4. Attachment D - Exit Interview Protocol for Attritor Sites Form and Instruction	New
Form 3 3. Attachment C - Safer Dx Checklist Form and Instruction	New
Form 2 2. Attachment B - Site Information Form Form and Instruction	New
Form 1 1. Attachment A - Site Interest Form Form and Instruction	New
Supporting Statement Part B Template__2024_1_24.docx Supporting Statement B	2024-06-12
Supporting Statement Part A - Implementation and Testing of Diagnostic Safety Resources.docx Supporting Statement A	2024-06-12

IC Document Collections

IC ID	Document Title	Status
268508	20. Attachment V - Patient Interview Protocol Form and Instruction	New
268507	19. Attachment U - Patient Toolkit Survey - Patient Form and Instruction	New
268506	18. Attachment T - Provider Interview Protocol Form and Instruction	New
268505	17. Attachment S - Patient Toolkit Survey-Provider Form and Instruction	New
268504	16. Attachment R - Provider Characteristics Form Form and Instruction	New
268503	15. Attachment Q - Clinical Self-Efficacy Survey Form and Instruction	New
268502	14. Attachment P - Calibrate Dx Survey Form and Instruction	New
268501	13. Omnibus Safety and Culture Survey Form and Instruction	New
268500	12. Attachment M - Diagnostic Safety Event Report Form and Instruction	New
268499	11. Attachment L - Measure Dx Declaration of Measurement Strategy Form and Instruction	New
268498	10. Attachment K - Measure Dx Organizational Self-Assessment Form and Instruction	New
268497	9. Attachment J - Implementation Interviews Protocol Form and Instruction	New
268492	8. Attachment I - Clinical Sustainability Assessment Tool (CSAT) Form and Instruction	New
268491	7. Attachment H - Post-Technical Assistance Evaluation Form Form and Instruction	New
268490	6. Attachment G - Post-training Evaluation Form Form and Instruction	New
268486	5. Diagnostic Safety Supplemental Set Form and Instruction	New
268405	4. Attachment D - Exit Interview Protocol for Attritor Sites Form and Instruction	New
268350	3. Attachment C - Safer Dx Checklist Form and Instruction	New
268349	2. Attachment B - Site Information Form Form and Instruction	New
268347	1. Attachment A - Site Interest Form Form and Instruction	New