POC Administration of the survey

Pretest of the Ambulatory Surgery/Procedure Survey on Patient Safety Culture

Documents and Forms

Document Name Document Type
Form Form # 3 POC Administration of the survey Form and Instruction
Form # 3 Site-level POC Instructions for Survey Attachment C - Site-level POC Instructions for Survey.docx Form and Instruction

Information Collection (IC) Details

IC Title:	POC Administration of the survey	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 and Instruction	Form # 3	Site-level POC Instructions for Survey	Attachment C - Site-level POC Instructions for Survey.docx		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 40	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 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	40	40
Annual IC Time Burden (Hours)	240	240
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.