Medical Office Information Form

Medical Office Survey on Patient Safety Culture Comparative Database

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0935-0196 can be found here:

Documents and Forms

Document Name Document Type
Form Form #3 Medical Office Information Form Form
Form #3 Medical Office Information Form Attachment C - Medical Office Site Information Form.docx Form
Form #3 Medical Office Information Form Attachment C - Medical Office Site Information Form.docx Form

Information Collection (IC) Details

IC Title:	Medical Office Information 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	Form #3	Medical Office Information Form	Attachment C - Medical Office Site Information Form.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 85	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: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	2,975	525	2,450
Annual IC Time Burden (Hours)	248	44	204
Annual IC Cost Burden (Dollars)	0	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.