3 Attachment D: Hospital Information Submission Form

Hospital Information Submission Form

Please provide the following information. The information you provide for data submission purposes will be kept confidential.

Hospital Name	Hospital Bed Size	State	Vendor Email
Sample Hospital	100	MD	name@vendor.com

Public reporting burden for this collection of information is estimated to average 5 minutes per response, the estimated time required to complete the form. 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.