Medical Office Eligibility and Registration Form

Medical Office Survey on Patient Safety Culture Comparative Database

Documents and Forms

Document Name Document Type
Form Form #1 Medical Office Eligibility and Registration Form Form and Instruction
Form #1 Medical Office Eligibility and Registration Form Attachment A - Medical Office Eligibility and Registration Form.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Medical Office Eligibility and Registration Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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	Form #1	Medical Office Eligibility and Registration Form	Attachment A - Medical Office Eligibility and Registration Form.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: 85	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 %

	Requested	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	85	85
Annual IC Time Burden (Hours)	4	4
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.