Pharmacy SOPS Registration Form

Pharmacy Survey on Patient Safety Culture Database

Documents and Forms

Document Name Document Type
Form 1 Pharmacy SOPS Registration Form Form and Instruction
1 Pharmacy SOPS Registration Form Attachment A - Pharmacy Eligibility and Registration Form_updated 6-13-17_clean.docx Form and Instruction
Attachment H - Example Screenshots of Pharmacy SOPS Data Submission Web Site.docx Attachment H: Example Screen Shots of Pharmacy SOPS Data Submission Web Site IC Document

Information Collection (IC) Details

IC Title:	Pharmacy SOPS Registration Form	Agency IC Tracking Number:

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	1	Pharmacy SOPS Registration Form	Attachment A - Pharmacy Eligibility and Registration Form_updated 6-13-17_clean.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 100	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	100	-50	150
Annual IC Time Burden (Hours)	8	-5	13
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Attachment H: Example Screen Shots of Pharmacy SOPS Data Submission Web Site	Attachment H - Example Screenshots of Pharmacy SOPS Data Submission Web Site.docx	02/27/2017

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