Medical Office Survey on Patient Safety Culture Comparative Database

Forms and Documents

Document Name	Status
Form Form #4 Data Submission Form	New
Form Form #3 Medical Office Information Form Form	New
Form Form #2 Data Use Agreement Form and Instruction	New
Form Form #1 Eligibility Form Form	New
Supporting Statement Part B -- MOSOPS Comparative Database 5-15-2012.doc Supporting Statement B	2012-05-29
Attachment H - TEP lists.doc Supplementary Document	2012-02-09
Attachment G - MO Expert Review Panel Members.doc Supplementary Document	2012-02-09
Attachment E - Sample Individual MO Feedback Report.pdf Supplementary Document	2012-02-09
Attachment A - MO SOPS questionnaire.doc Supplementary Document	2012-02-09
Attachment K - MO Data File Specs.pdf Supplementary Document	2012-02-09
Attachment I - Emails - MO SOPS Data Submission.doc Supplementary Document	2012-02-09
Supporting Statement Part A -- MOSOPS Comparative Database 5-15-2012.doc Supporting Statement A	2012-05-29

IC Document Collections

IC ID	Document Title	Status
201169	Data Submission Form	New
201168	Medical Office Information Form Form	New
201167	Data Use Agreement Form and Instruction	New
201166	Eligibility Form Form	New

ICR Details

OMB Control No: 0935-0196	ICR Reference No: 201202-0935-005
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/AHRQ	Agency Tracking No:
Title: Medical Office Survey on Patient Safety Culture Comparative Database
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 06/08/2012
	Date Received in OIRA: 02/13/2012
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2015	36 Months From Approved
Responses	1,950	0	0
Time Burden (Hours)	816	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The Agency for Healthcare Research and Quality (AHRQ) requests that the Office of Management and Budget (OMB) approve, under the Paperwork Reduction Act of 1995, AHRQ's collection of information for the AHRQ Medical Office Survey on Patient Safety Culture (Medical Office SOPS) Comparative Database. The Medical Office SOPS Comparative Database consists of data from the AHRQ Medical Office Survey on Patient Safety Culture. Medical offices in the U.S. are asked to voluntarily submit data from the survey to AHRQ, through its contractor, Westat. The Medical Office SOPS Database is modeled after the Hospital SOPS Database [OMB NO. 0935-0162; approved 05/04/2010] that was originally developed by AHRQ in 2006 in response to requests from hospitals interested in knowing how their patient safety culture survey results compare to those of other hospitals.

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Authorizing Statute(s): US Code: 42 USC 299 Name of Law: Healthcare Research and Quality Act of 1999
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 72929	11/28/2011
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 5023	02/01/2012
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 4

IC Title	Form No.	Form Name
Eligibility Form	Form #1	Medical Office SOPS Database Eligibility Form
Data Use Agreement	Form #2	Medical Office SOPS Database Data Use Agreement
Medical Office Information Form	Form #3	Medical Office Information Form
Data Submission	Form #4	Example Screen Shots of Web Site Information Collection

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ICR Summary of Burden

	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	1,950	0	0	1,950	0	0
Annual Time Burden (Hours)	816	0	0	816	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This is a new information collection request.

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Annual Cost to Federal Government: $310,000

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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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:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(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;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

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.

Certification Date: 02/13/2012

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