Attachment F Nursing Home Background Information Form

Pilot Test of the Proposed Workforce Safety Supplemental Item Set for the Surveys on Patient Safety Culture™, Supporting Statement A

Attachment F: Nursing Home Background Information Form

Draft Workforce Safety Supplemental Item Set

Nursing Home Background Information Form

3/8/2022

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.

SOPS® Nursing Home Survey with Workplace Safety Items

Pilot Test Background Information Form

Nursing Home Point of Contact: Please answer the background questions for each nursing home in your chain that is participating in the pilot test.

1. What is the name of your nursing home?_____________________________________________

What is the address of the nursing home? Street Address: ________________________________

City:__________________________ State:______________________ Zip code:_______________

2. What is your nursing home’s Medicare Provider ID (6 digits): _______________

3. Please identify the total number of skilled nursing licensed beds in this nursing home.

1. 1-49 beds

2. 50-99 beds

3. 100-199 beds

4. 200 or more beds

4. Please identify the type of organization that controls and operates the nursing home.

1. For Profit – Operated under

2. Non Profit – Operated under voluntary or other nonprofit auspices

3. Investor-owned (for-profit)

4. Government – Operated by a governmental entity