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Attachment A: ICU Assessment
Expanding the Comprehensive Unit-based Safety Program (CUSP) to reduceCentral Line-Associated Blood Stream Infections (CLABSI) and Catheter-Associated Urinary Tract Infections (CAUTI) in Intensive Ca
OMB: 0935-0240
IC ID: 229990
OMB.report
HHS/AHRQ
OMB 0935-0240
ICR 201802-0935-001
IC 229990
( )
Documents and Forms
Document Name
Document Type
Form 1
Attachment A: ICU Assessment
Form and Instruction
1 Attachment A ICU Assessment
Attachment A ICU Assessment.mam.docx
Form and Instruction
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Attachment A: ICU Assessment
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
1
Attachment A ICU Assessment
Attachment A ICU Assessment.mam.docx
Yes
Yes
Fillable Fileable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Health Care Services
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
150
Number of Respondents for Small Entity:
0
Affected Public:
Private Sector
Private Sector:
Not-for-profit institutions
Percentage of Respondents Reporting Electronically:
50 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
150
0
150
0
0
0
Annual IC Time Burden (Hours)
188
0
188
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
No associated records found
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.