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Data Submission
Medical Office Survey on Patient Safety Culture Comparative Database
OMB: 0935-0196
IC ID: 201169
OMB.report
HHS/AHRQ
OMB 0935-0196
ICR 201807-0935-002
IC 201169
( )
⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0935-0196 can be found here:
2024-10-02 - Reinstatement without change of a previously approved collection
2021-09-07 - Extension without change of a currently approved collection
Documents and Forms
Document Name
Document Type
Form Form #4
Data Submission
Form
Form #4 Example Screen Shots of Web Site Information Collection
Attachment E - Medical Office Survey Data File Specifications.pdf
Form
Attachment F - SOPS Databases TEP List.doc
Attachment F: Databases TEP List
IC Document
Attachment D - Medical Office Data Submission Emails.docx
Attachment D: Data Submission Emails
IC Document
Attachment G - Example Screenshots of MO SOPS Data Submission Web Site Information Collection.docx
Attachment G: Example Screen Shots of Medical Office Survey on Patient Safety Culture Data Submission Web Site Information Colle
IC Document
60 Day FRN.pdf
Federal Register Notice
IC Document
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Data Submission
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Modified
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
Form #4
Example Screen Shots of Web Site Information Collection
Attachment E - Medical Office Survey Data File Specifications.pdf
Yes
Yes
Fillable Fileable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Immunization Management
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
70
Number of Respondents for Small Entity:
0
Affected Public:
Private Sector
Private Sector:
Businesses or other for-profits, Not-for-profit institutions
Percentage of Respondents Reporting Electronically:
100 %
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
70
0
-80
0
0
150
Annual IC Time Burden (Hours)
70
0
-80
0
0
150
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
Attachment F: Databases TEP List
Attachment F - SOPS Databases TEP List.doc
07/25/2018
Attachment D: Data Submission Emails
Attachment D - Medical Office Data Submission Emails.docx
07/25/2018
Attachment G: Example Screen Shots of Medical Office Survey on Patient Safety Culture Data Submission Web Site Information Collection
Attachment G - Example Screenshots of MO SOPS Data Submission Web Site Information Collection.docx
07/25/2018
Federal Register Notice
60 Day FRN.pdf
07/25/2018
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.