Information Collection Request

Ambulatory Surgery Center Survey on Patient Safety Culture Database

ICR 202410-0935-003 · OMB 0935-0242 · Active

Forms and Documents

Forms and supporting documents for this ICR
DocumentTypeStatusAvailability
Form Form 4 SOPS ASC Survey Data Files Submission Form and Instruction Modified Available
Form Form 4 Attachment D - Data Files Submission Form and Instruction Modified Available
Form Form 2 ASC Site Information Form and Instruction Modified Available
Form Form 2 Attachment C - ASC Site Information Form Form and Instruction Modified Repair queued
Form Form 3 Data Use Agreement Form and Instruction Modified Repair queued
Form Form 3 Attachment B - Data Use Agreement Form and Instruction Modified Repair queued
Form Form 1 Attachment A - ASC Eligibility and Registration Form Form and Instruction Modified Repair queued
Form Form 1 Attachment A - ASC Eligibility and Registration Form Form and Instruction Modified Repair queued
Supporting Statement Part B -- ASC SOPS_Renewal 3-5-25.docx Supporting Statement B Uploaded 2025-04-08 Repair queued
OMB Passback_Jan 17 25_Supporting Statement Part A -- ASC SOPS_Extension 0935-0242_CLEAN.docx Supporting Statement A Uploaded 2025-04-08 Repair queued
Supporting Statement Part A -- ASC SOPS_Extension 0935-0242 10.2.24.docx Supporting Statement A Uploaded 2024-10-17 Repair queued
Attachment G - Example Screenshots of SOPS ASC Data Submission Website.docx Supplementary Document Uploaded 2024-10-17 Available
Attachment G - Example Screenshots of SOPS ASC Data Submission Website.docx Supplementary Document Uploaded 2024-10-17 Missing upstream
Attachment F - SOPS Technical Expert Panel (TEP) List.docx Supplementary Document Uploaded 2024-10-17 Available
Attachment F - SOPS Technical Expert Panel (TEP) List.docx Supplementary Document Uploaded 2024-10-17 Repair queued
Attachment E - Survey Data File Specifications.docx Supplementary Document Uploaded 2024-10-17 Available
Attachment E - Survey Data File Specifications.docx Supplementary Document Uploaded 2024-10-17 Repair queued

IC Document Collections

Information collection document groups
IC IDCollectionTypeStatusForm
232084 Attachment D - Data Files Submission Form and Instruction ModifiedSOPS ASC Survey Data Files Submission
232084 Attachment D - Data Files Submission Form and Instruction Modified
232083 Attachment C - ASC Site Information Form Form and Instruction ModifiedASC Site Information
232083 Attachment C - ASC Site Information Form Form and Instruction Modified
232082 Attachment B - Data Use Agreement Form and Instruction ModifiedData Use Agreement
232082 Attachment B - Data Use Agreement Form and Instruction Modified
232081 Attachment A - ASC Eligibility and Registration Form Form and Instruction ModifiedAttachment A - ASC Eligibility and Registration Form
232081 Attachment A - ASC Eligibility and Registration Form Form and Instruction Modified

ICR Details

Reginfo record details
table that charts list comparision
  Inventory as of this Action Requested Previously Approved
04/30/2028 36 Months From Approved 04/30/2025
420 0 400
86 0 121
0 0 0





Reginfo record details
4
table that charts list of burden
IC Title Form No. Form Name
Attachment A - ASC Eligibility and Registration Form Form 1
Attachment B - Data Use Agreement Form 3
Attachment C - ASC Site Information Form Form 2
Attachment D - Data Files Submission Form 4

table that charts list of burden
  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 420 400 0 20 0 0
Annual Time Burden (Hours) 86 121 0 -35 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0


Reginfo record details
  No