Information Collection Request

Implementation and Testing of Diagnostic Safety Resources

ICR 202406-0935-001 · OMB unassigned · Received in OIRA

Forms and Documents

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

IC Document Collections

Information collection document groups
IC ID	Collection	Type	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

ICR Details

Record metadata
Status	Received in OIRA
Agency/Subagency	HHS/AHRQ
Type of Information Collection	New collection (Request for a new OMB Control Number)
Date Submitted to OIRA	1969-12-31
Requested Expiration Date	1969-12-31