Ambulatory Surgery Center Survey on Patient Safety Culture Database

ICR 202410-0935-003

OMB: 0935-0242

Federal Form Document

Forms and Documents

Document Name	Status
Form Form 4 Attachment D - Data Files Submission Form and Instruction	Modified
Form Form 2 Attachment C - ASC Site Information Form Form and Instruction	Modified
Form Form 3 Attachment B - Data Use Agreement Form and Instruction	Modified
Form Form 1 Attachment A - ASC Eligibility and Registration Form Form and Instruction	Modified
Supporting Statement Part A -- ASC SOPS_Extension 0935-0242 10.2.24.docx Supporting Statement A	2024-10-17
Attachment G - Example Screenshots of SOPS ASC Data Submission Website.docx Supplementary Document	2024-10-17
Attachment F - SOPS Technical Expert Panel (TEP) List.docx Supplementary Document	2024-10-17
Attachment E - Survey Data File Specifications.docx Supplementary Document	2024-10-17

IC Document Collections

IC ID	Document Title	Status
232084	Attachment D - Data Files Submission Form and Instruction	Modified
232083	Attachment C - ASC Site Information Form Form and Instruction	Modified
232082	Attachment B - Data Use Agreement Form and Instruction	Modified
232081	Attachment A - ASC Eligibility and Registration Form Form and Instruction	Modified