Form # 1 Form # 1 Attachment A: Hospital Eligibility and Registration Form

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

AHRQ Hospital Survey on Patient Safety Culture Database, Supporting Statement A

Attachment A: Eligibility and Registration Form

Public reporting burden for this collection of information is estimated to average 3 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, 5600 Fishers Lane, Rockville, MD 20857.