Information Collection

57.103 Patient Safety Component - Annual Hospital Survey

IC 183572 under ICR 202603-0920-006 · OMB 0920-0666.

Documents and Forms

Document Name Document Type
Form 57.103 Patient Safety Component-Annual Hospital Survey 57.103 Patient Safety Component - Annual Hospital Survey Form and Instruction
57.103 Patient Safety Component-Annual Hospital Survey 57.103 ACH Annual Facility Survey-Clean Version.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	57.103 Patient Safety Component - Annual Hospital Survey	Agency IC Tracking Number:	0920-0666

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	57.103	Patient Safety Component-Annual Hospital Survey	57.103 ACH Annual Facility Survey-Clean Version.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 5,400	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	5,400	0	5,400
Annual IC Time Burden (Hours)	12,420	90	12,330
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.

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