Form #3 Form #3 Medical Office Information Form

Form Approved
OMB No. 0935-XXXX
Exp. Date XX/XX/20XX

AHRQ Medical Office Survey on Patient Safety Culture Comparative Database, Supporting Statement A

Attachment C: Medical Office Site Information Form

Public reporting burden for this collection of information is estimated to average 5 minutes per response, the estimated time required to complete the survey. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-XXXX) AHRQ, 540 Gaither Road, Room # 5036, Rockville, MD 20850.