Form 3 The Safer Dx Checklist: 10 High-Priority Practices for D

Attachment C: Safer Dx Checklist

Form Approved
OMB No. 0935-XXXX
Exp. Date XX/XX/20XX

Please complete the following organizational self-assessment; it should take no longer than 15 minutes to complete.

For each of the 10 checklist items, team members from the organization (either individually or as a group) should select the Implementation Status that best represents the current state of their organization’s practices:

• Full: A well-known and well-documented practice that occurs reliably in the organization.

• Partial: The practice occurs in the organization sometimes. While it is well-documented, the practice is not well known or it may be implemented inconsistently across the organization.

• Not Implemented: This practice does not occur in the organization.

This survey is authorized under 42 U.S.C. 299a. This information collection is voluntary and the confidentiality of your responses to this survey is protected by Sections 944(c) and 308(d) of the Public Health Service Act [42 U.S.C. 299c-3(c) and 42 U.S.C. 242m(d)]. Information that could identify you will not be disclosed unless you have consented to that disclosure. Public reporting burden for this collection of information is estimated to average 15 minutes per response, the estimated time required to complete the survey. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The data you provide will help AHRQ’s mission to produce evidence to make health care safer, higher quality, more accessible, equitable, and affordable. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-xxxx) AHRQ, 5600 Fishers Lane, Room #07W42, Rockville, MD 20857, or by email to the AHRQ MEPS Project Director at [email protected].