Eligibility/Registration Form and Data Submission

Collection of Information for AHRQ's Hospital Survey on Patient Safety Culture Comparative Database

Documents and Forms

Document Name Document Type
Form Form # 1 Eligibility/Registration Form and Data Submission Form and Instruction
Form # 1 Attachment A: Hospital Eligibility and Registration Form Attachment A - Eligibility and Registration Form - 3-1-22.docx Form and Instruction
Form # 1 Attachment A: Hospital Eligibility and Registration Form Attachment A - Eligibility and Registration Form - 3-1-22.docx Form and Instruction
Attachment I -- Emails for Hospital SOPS Data Submission.doc Attachment I -- Emails for Hospital SOPS Data Submission IC Document
Attachment I -- Emails for Hospital SOPS Data Submission.doc Attachment I -- Emails for Hospital SOPS Data Submission IC Document
Attachment J -- Screen Shots Hospital SOPS Forms.doc Attachment J -- Screen Shots Hospital SOPS Forms IC Document
Attachment J -- Screen Shots Hospital SOPS Forms.doc Attachment J -- Screen Shots Hospital SOPS Forms IC Document
Attachment K -- HSOPS Survey Data File Specifications.docx Attachment K -- HSOPS Survey Data File Specifications IC Document
Attachment K -- HSOPS Survey Data File Specifications.docx Attachment K -- HSOPS Survey Data File Specifications IC Document

Information Collection (IC) Details

IC Title:	Eligibility/Registration Form and Data Submission	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	Form # 1	Attachment A: Hospital Eligibility and Registration Form	Attachment A - Eligibility and Registration Form - 3-1-22.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 340	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	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	340	340
Annual IC Time Burden (Hours)	17	17
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Attachment I -- Emails for Hospital SOPS Data Submission	Attachment I -- Emails for Hospital SOPS Data Submission.doc	07/31/2013
Attachment J -- Screen Shots Hospital SOPS Forms	Attachment J -- Screen Shots Hospital SOPS Forms.doc	07/31/2013
Attachment K -- HSOPS Survey Data File Specifications	Attachment K -- HSOPS Survey Data File Specifications.docx	07/31/2013

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