Organizational Leader Questionnaire

Assessing the Impact of the Patient Safety Improvement Corps (PSIC) Training Program

Documents and Forms

Document Name Document Type
Form Form #2 Organizational Leader Questionnaire Form and Instruction
Form #2 Organizational leader questionnaire Attachment D -- PSIC leadership questionnaire 06-23-08.doc Form and Instruction
Attachment F -- AHRQ PSIC Leadership -- All Letters 06-24-08.doc Attachment F -- AHRQ PSIC Leadership -- All Letters 06-24-08 IC Document

Information Collection (IC) Details

IC Title:	Organizational Leader Questionnaire	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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 #2	Organizational leader questionnaire	Attachment D -- PSIC leadership questionnaire 06-23-08.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 75	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	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	75	75
Annual IC Time Burden (Hours)	19	19
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Attachment F -- AHRQ PSIC Leadership -- All Letters 06-24-08	Attachment F -- AHRQ PSIC Leadership -- All Letters 06-24-08.doc	07/21/2008

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