Form #1 Form #1 Medical Office SOPS Database Eligibility Form

A

Form Approved
OMB No. 0935-XXXX
Exp. Date XX/XX/20XX

ttachment B

Medical Office Survey on Patient Safety Culture Database Eligibility Form

We welcome your interest! To determine your organization’s eligibility for participation in the Medical Office Survey on Patient Safety Culture Comparative Database, we need to collect some information about you and your survey.

*1. Which of the following do you represent?

• Medical office/health system

• Quality Improvement Organization (QIO)

• An organization or vendor submitting data on behalf of a medical office or health system

• Another type of healthcare organization (please specify) ____________________

*2. Will you have completed survey data collection and be able to submit your final electronic data file by October 15, 2011?

• Yes

• No

*3. How many medical offices will you be submitting for? ______________

*4. Did you make any changes to the AHRQ Medical Office SOPS Questionnaire?

• Yes

• No

*If yes, please describe the changes (select all that apply).

• Added/Revised staff positions

• Added items

• Removed items

• Modified wording of item text

• Modified response options

• Reordered the items

• Other (please specify)_________

• Organization Name: _____________________

• First Name:____________________________

• Last Name:____________________________

• Title/Position:_________________________

• Address1:____________________________

• Address2:____________________________

• City:________________________________

• State:_______________________________

• Zip Code:____________________________

• Telephone number____________________

• Ext:________________________________

• Email Address:_______________________

• Confirm Email Address:________________

Public reporting burden for this collection of information is estimated to average 3 minutes per response, the estimated time required to complete the survey. 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, 540 Gaither Road, Room # 5036, Rockville, MD 20850.