Information Collection

5. Diagnostic Safety Supplemental Set

IC 268486 under ICR 202406-0935-001 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 5a 5. Diagnostic Safety Supplemental Set	Form and Instruction
5a Medical Office Survey on Patient Safety Attachment E - SOPS Medical Office Survey with Diagnostic Safety Supplemental Item Set.2024_5_24.docx	Form and Instruction
5a Medical Office Survey on Patient Safety Attachment E - SOPS Medical Office Survey with Diagnostic Safety Supplemental Item Set.2024_5_24.docx	Form and Instruction
5b Hospital Survey on Patient Safety Attachment F - SOPS Hospital Survey with Diagnostic Safety Supplemental Item Set.2024_5_24.docx	Form and Instruction
5b Hospital Survey on Patient Safety Attachment F - SOPS Hospital Survey with Diagnostic Safety Supplemental Item Set.2024_5_24.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	5a	Medical Office Survey on Patient Safety	Attachment E - SOPS Medical Office Survey with Diagnostic Safety Supplemental Item Set.2024_5_24.docx		Yes	Yes	Fillable Fileable
Form and Instruction	5b	Hospital Survey on Patient Safety	Attachment F - SOPS Hospital Survey with Diagnostic Safety Supplemental Item Set.2024_5_24.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 219

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: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	219	219
Annual IC Time Burden (Hours)	55	55
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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