Nursing Home SOPS Data File Submission

Nursing Home Survey on Patient Safety Culture Comparative Database

Documents and Forms

Document Name Document Type
Form Form 4 Nursing Home SOPS Data File Submission Form and Instruction
Form 4 Nursing Home SOPS Data File Submission Attachment D - Nursing Home Data File Submission.docx Form and Instruction
Attachment K - NH Submission Home Page.docx Attachment K - NH Submission Home Page IC Document
Attachment I - Emails - NH SOPS Data Submission.doc Attachment I - Emails - NH SOPS Data Submission IC Document
Attachment L - NH Questionnaire Upload Page.docx Attachment L - NH Questionnaire Upload Page IC Document
Attachment M - NH SOPS Data Submission Specs.pdf Attachment M - NH SOPS Data Submission Specs IC Document

Information Collection (IC) Details

IC Title:	Nursing Home SOPS Data File 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 4	Nursing Home SOPS Data File Submission	Attachment D - Nursing Home Data File Submission.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 50	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 %

	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	50	10	40
Annual IC Time Burden (Hours)	50	10	40
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Attachment K - NH Submission Home Page	Attachment K - NH Submission Home Page.docx	01/31/2012
Attachment I - Emails - NH SOPS Data Submission	Attachment I - Emails - NH SOPS Data Submission.doc	01/31/2012
Attachment L - NH Questionnaire Upload Page	Attachment L - NH Questionnaire Upload Page.docx	01/31/2012
Attachment M - NH SOPS Data Submission Specs	Attachment M - NH SOPS Data Submission Specs.pdf	01/31/2012

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