Clinical Outcomes Data

The AHRQ Safety Program for Healthcare Associated Infection Prevention

Documents and Forms

Document Name Document Type
Form 5 Clinical Outcomes Data Form
Attachment J - Submission Guide for Clinical Outcomes Data Collection.docx Instruction
5 Clinical Outcomes Data Template Attachment I - Clinical Outcomes Data Template.docx Form

Information Collection (IC) Details

IC Title:	Clinical Outcomes Data	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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	5	Clinical Outcomes Data Template	Attachment I - Clinical Outcomes Data Template.docx		Yes	Yes	Fillable Fileable
Instruction			Attachment J - Submission Guide for Clinical Outcomes Data Collection.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 100	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 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	400	400
Annual IC Time Burden (Hours)	500	500
Annual IC Cost Burden (Dollars)	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.