Department of Defense (DoD) Patient Safety Culture Survey

ICR 200911-0720-005

OMB: 0720-0034

Federal Form Document

Forms and Documents
Document
Name
Status
Supporting Statement B
2009-11-16
Supporting Statement A
2009-11-16
IC Document Collections
ICR Details
0720-0034 200911-0720-005
Historical Active 200507-0720-002
DOD/DODOASHA
Department of Defense (DoD) Patient Safety Culture Survey
Reinstatement without change of a previously approved collection   No
Regular
Approved without change 01/14/2010
Retrieve Notice of Action (NOA) 11/16/2009
  Inventory as of this Action Requested Previously Approved
01/31/2013 36 Months From Approved
14,022 0 0
2,384 0 0
0 0 0

Anonymous web based survey to gather information from DoD Military Healthy System (MHS) personnel on their opinions of patient safety in their MHS operational environment to fulfill Congressionally-mandated DoD Patient Safety Program.

None
None

Not associated with rulemaking

  73 FR 57062 10/01/2008
73 FR 57062 10/01/2008
No

1
IC Title Form No. Form Name
Department of Defense (DoD) Patient Safety Culture Survey

  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 14,022 0 0 0 0 14,022
Annual Time Burden (Hours) 2,384 0 0 0 0 2,384
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$270,349
Yes Part B of Supporting Statement
No
Uncollected
Uncollected
No
Uncollected
Patricia Toppings 703 696-5284 PLToppings@whs.mil

  No

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
11/13/2009


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