5. Diagnostic Safety Supplemental Set

Implementation and Testing of Diagnostic Safety Resources

Documents and Forms

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

Information Collection (IC) Details

IC Title:	5. Diagnostic Safety Supplemental Set	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection 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 %

	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

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.