Information Collection Request

Medical Office Survey on Patient Safety Culture Comparative Database

ICR 202504-0935-001 · OMB 0935-0196 · Active

Forms and Documents

Forms and supporting documents for this ICR
DocumentTypeStatusAvailability
Form Form #4 Medical Office Data Submission Emails Form and Instruction Unchanged Available
Form Form #4 Medical Office SOPS Data Submission Emails Form and Instruction Unchanged Repair queued
Form Form #3 Medical Office SOPS Data Use Agreement Form and Instruction Modified Available
Form Form #3 Medical Office SOPS Data Use Agreement Form and Instruction Unchanged Repair queued
Form Form #2 Medical Office Site Information Form Form and Instruction Unchanged Available
Form Form #2 Medical Office Site Information Form Form and Instruction Unchanged Repair queued
Form Form #1 Medical Office Eligibility and Registration Form Form and Instruction Modified Available
Form Form #1 Medical Office Eligibility and Registration Form Form and Instruction Unchanged Repair queued
Supporting Statement Part B -- 0935-0196 Medical Office SOPS_Extension.docx Supporting Statement B Uploaded 2025-04-07 Available
Supporting Statement Part B -- 0935-0196 Medical Office SOPS_Extension.docx Supporting Statement B Uploaded 2025-04-07 Repair queued
Supporting Statement Part A -- 0935-0196 Medical Office SOPS_Extension - OMB_passback_CLEAN.docx Supporting Statement A Uploaded 2025-08-04 Available
Supporting Statement Part A -- 0935-0196 Medical Office SOPS_Extension.docx Supporting Statement A Uploaded 2025-04-07 Repair queued
Attachment F - SOPS Technical Expert Panel (TEP) List.docx Supplementary Document Uploaded 2024-09-26 Available
Attachment F - SOPS Technical Expert Panel (TEP) List.docx Supplementary Document Uploaded 2024-09-26 Repair queued
Attachment E - AHRQ Medical Office SOPS Survey Data File Specifications.pdf Supplementary Document Uploaded 2024-09-26 Available
Attachment E - AHRQ Medical Office SOPS Survey Data File Specifications.pdf Supplementary Document Uploaded 2024-09-26 Available
Attachment G - Example Screenshots of MO SOPS Data Submission Website Information Collection.docx Supplementary Document Uploaded 2024-09-26 Available
Attachment G - Example Screenshots of MO SOPS Data Submission Website Information Collection.docx Supplementary Document Uploaded 2024-09-26 Repair queued

IC Document Collections

Information collection document groups
IC IDCollectionTypeStatusForm
201169 Medical Office SOPS Data Submission Emails Form and Instruction UnchangedMedical Office Data Submission Emails
201169 Medical Office SOPS Data Submission Emails Form and Instruction Unchanged
201168 Medical Office SOPS Data Use Agreement Form and Instruction ModifiedMedical Office SOPS Data Use Agreement
201168 Medical Office SOPS Data Use Agreement Form and Instruction Unchanged
201167 Medical Office Site Information Form Form and Instruction UnchangedMedical Office Site Information Form
201167 Medical Office Site Information Form Form and Instruction Unchanged
201166 Medical Office Eligibility and Registration Form Form and Instruction ModifiedMedical Office Eligibility and Registration Form
201166 Medical Office Eligibility and Registration Form Form and Instruction Unchanged

ICR Details

Reginfo record details
table that charts list comparision
  Inventory as of this Action Requested Previously Approved
08/31/2028 36 Months From Approved
2,805 0 0
308 0 0
0 0 0





Reginfo record details
4
table that charts list of burden
IC Title Form No. Form Name
Medical Office Eligibility and Registration Form Form #1
Medical Office SOPS Data Submission Emails Form #4
Medical Office SOPS Data Use Agreement Form #3
Medical Office Site Information Form Form #2

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 2,805 0 0 -425 0 3,230
Annual Time Burden (Hours) 308 0 0 -33 0 341
Annual Cost Burden (Dollars) 0 0 0 0 0 0


Reginfo record details
  No