Information Collection Request

Collection of Information for AHRQ's Hospital Survey on Patient Safety Culture Comparative Database

ICR 202512-0935-004 · OMB 0935-0162 · Active

Forms and Documents

Forms and supporting documents for this ICR
DocumentTypeStatusAvailability
Form 4 Data Submission Emails Form and Instruction New Available
Form 4 Attachment D- Data File Emails Form and Instruction New Repair queued
Form 3 Attachment C Data Use Agreement Form and Instruction New Available
Form 3 Attachment C- Data Use Agreement Form and Instruction New Repair queued
Form 2 Hospital Site Information Form and Instruction New Repair queued
Form 2 Hospital Site Information Form and Instruction New Repair queued
Form 1 Hospital Eligibility and Registration Form Form and Instruction New Available
Form 1 Hospital Eligibility and Registration Form Form and Instruction New Repair queued
Form Attachment D Data Files Submission Form and Instruction Removed Available
Form Attachment D Data Files Submission Form and Instruction Removed Repair queued
Form Form # 3 Attachment C: Hospital Site Information Form Form and Instruction Removed Available
Form Form # 3 Hospital Information Form Form and Instruction Removed Repair queued
Form Form # 2 Attachment B: Hospital Data Use Agreement Form and Instruction Removed Available
Form Form # 2 Data Use Agreement Form and Instruction Removed Repair queued
Form Form # 1 Attachment A: Hospital Eligibility and Registration Form Form and Instruction Removed Repair queued
Form Form # 1 Eligibility/Registration Form and Data Submission Form and Instruction Removed Repair queued
Attachment G - Example Screenshots of Hospital SOPS Data Submission Web Site - 3-4-25.docx Supplementary Document Uploaded 2026-01-05 Repair queued
Attachment G - Example Screenshots of Hospital SOPS Data Submission Web Site - 3-4-25.docx Supplementary Document Uploaded 2026-01-05 Repair queued
Attachment F - Databases TEP List_2-28-25.docx Supplementary Document Uploaded 2026-01-05 Available
Attachment F - Databases TEP List_2-28-25.docx Supplementary Document Uploaded 2026-01-05 Repair queued
Attachment E - Survey Data File Specifications - 3-4-2025.pdf Supplementary Document Uploaded 2026-01-05 Available
Attachment E - Survey Data File Specifications - 3-4-2025.pdf Supplementary Document Uploaded 2026-01-05 Repair queued
Supporting Statement Part A -- HSOPS DB Renewal_2-13-26.docx Supporting Statement A Uploaded 2026-02-16 Available
Supporting Statement Part A -- HSOPS DB Renewal_1 5 26.docx Supporting Statement A Uploaded 2026-01-05 Repair queued
Supporting Statement Part B -- HSOPS DB Renewal_6-9-25.docx Supporting Statement B Uploaded 2025-12-30 Available
Supporting Statement Part B -- HSOPS DB Renewal_6-9-25.docx Supporting Statement B Uploaded 2025-12-30 Repair queued

IC Document Collections

Information collection document groups
IC IDCollectionTypeStatusForm
278643 Attachment D- Data File Emails Form and Instruction NewData Submission Emails
278643 Attachment D- Data File Emails Form and Instruction New
278642 Attachment C- Data Use Agreement Form and Instruction NewAttachment C Data Use Agreement
278642 Attachment C- Data Use Agreement Form and Instruction New
278419 Hospital Site Information Form and Instruction NewHospital Site Information
278419 Hospital Site Information Form and Instruction New
278418 Hospital Eligibility and Registration Form Form and Instruction NewHospital Eligibility and Registration Form
278418 Hospital Eligibility and Registration Form Form and Instruction New
236390 Data Files Submission Form and Instruction RemovedData Files Submission
236390 Data Files Submission Form and Instruction Removed
191670 Hospital Information Form Form and Instruction RemovedAttachment C: Hospital Site Information Form
191670 Hospital Information Form Form and Instruction Removed
191668 Data Use Agreement Form and Instruction RemovedAttachment B: Hospital Data Use Agreement
191668 Data Use Agreement Form and Instruction Removed
191667 Eligibility/Registration Form and Data Submission Form and Instruction RemovedAttachment A: Hospital Eligibility and Registration Form
191667 Eligibility/Registration Form and Data Submission Form and Instruction Removed

ICR Details

Reginfo record details
table that charts list comparision
  Inventory as of this Action Requested Previously Approved
02/28/2029 36 Months From Approved
990 0 0
222 0 0
31,878 0 0





Reginfo record details
4
table that charts list of burden
IC Title Form No. Form Name
Attachment C- Data Use Agreement 3
Attachment D- Data File Emails 4
Data Files Submission Attachment D
Data Use Agreement Form # 2
Eligibility/Registration Form and Data Submission Form # 1
Hospital Eligibility and Registration Form 1
Hospital Information Form Form # 3
Hospital Site Information 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 990 0 0 0 -1,050 2,040
Annual Time Burden (Hours) 222 0 0 0 -237 459
Annual Cost Burden (Dollars) 31,878 0 0 -270 32,148 0


Reginfo record details
  No