Attachment A - ASC Eligibility and Registration Form

Ambulatory Surgery Center Survey on Patient Safety Culture Database

Documents and Forms

Document Name Document Type
Form Form 1 Attachment A - ASC Eligibility and Registration Form Form and Instruction
Form 1 ASC Eligibility and Registration Form Attachment A - ASC Eligibility and Registration Form.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Attachment A - ASC 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	ASC Eligibility and Registration Form			Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 60	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	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	60	-40	100
Annual IC Time Burden (Hours)	3	-5	8
Annual IC Cost Burden (Dollars)	0	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.