Information Collection

Building Diagnostic Safety Capacity - Diagnostic Safety Measurement Resource Evaluation Plan

IC 245332 under ICR 202501-0935-001 · OMB 0935-0179.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Building Diagnostic Safety Capacity - Diagnostic Safety Measurement Resource Evaluation Plan	Form and Instruction
Form 1 Appendix A: Organizational Characteristics Survey Building Diagnostic Safety Capacity - Diagnostic Safety Measurement Resource Evaluation Plan	Form and Instruction
Form 2 Appendix B: Organizational Readiness for Implementation Change (ORIC) Building Diagnostic Safety Capacity - Diagnostic Safety Measurement Resource Evaluation Plan	Form and Instruction
Form 3 Appendix C: Pre-Test Interview Protocol Building Diagnostic Safety Capacity - Diagnostic Safety Measurement Resource Evaluation Plan	Form and Instruction
Form 3 Appendix D: Post-test Evaluation Interview Protocol Building Diagnostic Safety Capacity - Diagnostic Safety Measurement Resource Evaluation Plan	Form and Instruction
1 Appendix A: Organizational Characteristics Survey Appendix A_Organizational Characteristics Survey.docx	Form and Instruction
1 Appendix A: Organizational Characteristics Survey Appendix A_Organizational Characteristics Survey.docx	Form and Instruction
2 Appendix B: Organizational Readiness for Implementation Appendix B_ORIC.docx	Form and Instruction
2 Appendix B: Organizational Readiness for Implementation Appendix B_ORIC.docx	Form and Instruction
3 Appendix C: Pre-Test Interview Protocol Appendix C_Pre-test Interview Protocol.docx	Form and Instruction
3 Appendix C: Pre-Test Interview Protocol Appendix C_Pre-test Interview Protocol.docx	Form and Instruction
3 Appendix D: Post-test Evaluation Interview Protocol Appendix D_Post-test Interview Protocol.docx	Form and Instruction
3 Appendix D: Post-test Evaluation Interview Protocol Appendix D_Post-test Interview Protocol.docx	Form and Instruction
OMB Cover Letter.docx Cover Letter	IC Document
OMB Cover Letter.docx Cover Letter	IC Document
Supporting Statement A_Operational Measurement_final ms.docx Supporting Statement	IC Document
Supporting Statement A_Operational Measurement_final ms.docx Supporting Statement	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Building Diagnostic Safety Capacity - Diagnostic Safety Measurement Resource Evaluation Plan

Agency IC Tracking Number:

IC Status: Removed

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Electronic Capability
Form and Instruction	1	No	Paper Only
Form and Instruction	2	No	Paper Only
Form and Instruction	3	No	Paper Only
Form and Instruction	3	No	Paper Only

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 160

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: 0 %

table that charts list of burden
	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	-160	160
Annual IC Time Burden (Hours)	-155	155
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Cover Letter		01/13/2021
Supporting Statement		01/13/2021

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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