Safety event intake form and follow up

A PROTOTYPE CONSUMER REPORTING SYSTEM FOR PATIENT SAFETY EVENTS

Documents and Forms

Document Name Document Type
Form Form #1 Safety event intake form and follow up Form and Instruction
Form #1 Intake reporting form - web version Attachment B -- Intake Reporting Form - Web Version.doc Form and Instruction
Form #2 Intake reporting form - phone version Attachment D -- Intake Reporting Form -- Phone Version.doc Form and Instruction
Form #3 Intake reporting form follow up Attachment E -- Intake Reporting Form Follow Up.doc Form and Instruction
Attachment A -- Introductory Pages of Website.docx Attachment A -- Introductory Pages of Website IC Document
Attachment C -- FAQs List.docx Attachment C -- FAQs List IC Document
Attachment F -- Marketing Flyer.pdf Attachment F -- Marketing Flyer IC Document

Information Collection (IC) Details

IC Title:	Safety event intake form and follow up	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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	Form #1	Intake reporting form - web version	Attachment B -- Intake Reporting Form - Web Version.doc	Yes	Yes	Fillable Fileable
Form and Instruction	Form #2	Intake reporting form - phone version	Attachment D -- Intake Reporting Form -- Phone Version.doc	Yes	Yes	Fillable Fileable
Form and Instruction	Form #3	Intake reporting form follow up	Attachment E -- Intake Reporting Form Follow Up.doc	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 840	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	840	840
Annual IC Time Burden (Hours)	490	490
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Attachment A -- Introductory Pages of Website	Attachment A -- Introductory Pages of Website.docx	06/06/2013
Attachment C -- FAQs List	Attachment C -- FAQs List.docx	06/06/2013
Attachment F -- Marketing Flyer	Attachment F -- Marketing Flyer.pdf	06/06/2013

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.