Form #1 Form #1 Medical Office Eligibility and Registration Form

AHRQ Medical Office Survey on Patient Safety Culture Database, Supporting Statement A

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

Attachment A: Medical Office Eligibility and Registration Form

*4. How many medical offices will you be submitting for?

*5. Did you administer the SOPS Value and Efficiency Supplemental Item Set with your SOPS Medical Office Survey?

*2. Will you have completed survey data collection and be able to submit your final electronic data file by October 20, 2021?

*5. Did you administer the SOPS Value and Efficiency Supplemental Item Set with your SOPS Medical Office Survey?

*4. How many medical offices will you be submitting for?

Public reporting burden for this collection of information is estimated to average 3 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.  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, 540 Gaither Road, Room # 5036, Rockville, MD 20850.