OMB.report

Federal forms, ICRs, and supporting documents

OMB control number

A Prototype Consumer Reporting System For Patient Safety Events

OMB 0935-0214 · HHS/AHRQ.

OMB 0935-0214

Latest Forms, Documents, and Supporting Material

Document Name
Form Form #4 Health care provider follow up Form and Instruction
Form Form #1 Safety event intake form and follow up Form and Instruction
SA Part B -- A Prototype Consumer Reporting Sys for PS Events_3-20-2013.docx Supporting Statement B
Attachment J -- Illustrative example of no-retaliation policy.pdf Supplementary Document
Attachment H -- Revisions and Responses to FRN Comments.docx Supplementary Document
Attachment I -- Public Comments.pdf Supplementary Document
Attachment L -- Federal Register Notice.pdf Supplementary Document
Attachment K -- Example of process and policy for no-blame policy for providers.pdf Supplementary Document
Attachment F -- Marketing Flyer.pdf Supplementary Document
Attachment C -- FAQs List.docx Supplementary Document
Attachment A -- Introductory Pages of Website.docx Supplementary Document
SS Part A -- A Prototype Consumer Reporting Sys for PS Events 6-6-2013.docx Supporting Statement A
Health care provider follow up Form and Instruction
Safety event intake form and follow up Form and Instruction

All Historical Document Collections

201306-0935-001

Approved without change

New collection (Request for a new OMB Control Number)

2013-06-10