Form #3 Form #3 Medical Office Information Form

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

AHRQ Medical Office Survey on Patient Safety Culture Comparative Database, Supporting Statement A

Attachment C: Medical Office Site Information Form

Response options for Specialties (separated by semi-colons):

Allergy/Immunology; Anesthesiology; Cardiology; Child & Adolescent Psychiatry; Dermatology; Diagnostic Radiology; Emergency Medicine; Endocrinology/ Metabolism; Family Practice/Family Medicine; Forensic Pathology; Gastroenterology; General Practice

Response options for Practice Type:

• Single specialty

• Multispecialty

Response options for Majority Ownership:

• Provider(s) and/or Physician(s)

• Hospital or Health System

• University or Academic Medical Center

• Community Health Center

• Federal, state, or local government

• Other

Response options for Survey Mode:

• Paper

• Web

• Mixed mode (paper & web)

• Other

Public reporting burden for this collection of information is estimated to average 5 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.