Pilot Test of the Proposed Workplace Safety Supplemental Item Set For the AHRQ Surveys on Patient Safety Culture™ (SOPS®) Nursing Home Survey

Questionnaire and Data Collection Testing, Evaluation, and Research for the Agency for Healthcare Research and Quality

OMB: 0935-0124

IC ID: 251418

Documents and Forms
Document Name
Document Type
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
IC Document
IC Document
IC Document
IC Document
IC Document
IC Document
IC Document
IC Document
IC Document
IC Document
Information Collection (IC) Details

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Pilot Test of the Proposed Workplace Safety Supplemental Item Set For the AHRQ Surveys on Patient Safety Culture™ (SOPS®) Nursing Home Survey
 
Unchanged
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction 1 Attachment B: Draft Workplace Safety Cognitive Interview Guide Attachment B - Draft NH Workplace Safety Cognitive Interview Guide.docx Yes Yes Fillable Fileable
Form and Instruction 2 Attachment C: Nursing Home Point of Contact (POC) Instructions Attachment C - Nursing Home Point of Contact (POC) Instructions.docx Yes Yes Fillable Fileable
Form and Instruction 3 Attachment A: Draft Workplace Safety Supplemental Item Set 04CB6620.DOC.docx Yes Yes Fillable Fileable
Form and Instruction Attachment F Nursing Home Background Information Form Attachment F - Nursing Home Background Information Form.docx Yes Yes Fillable Fileable

Health Health Care Services

 

4,309 0
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   50 %

  Requested 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 4,309 0 0 0 0 4,309
Annual IC Time Burden (Hours) 1,432 0 0 0 0 1,432
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Cover Letter OMB Cover Letter.docx 02/03/2022
Supporting Statement Part A Supporting Statement Part A clean.docx 03/11/2022
Supporting Statement Part B Supporting Statement Part B.docx 02/03/2022
Attachment D: Survey Invitation and Reminder Notices Attachment D - Survey Invitation and Reminder Notices.docx 02/03/2022
Attachment E: Subject Matter Experts and Technical Expert Panel Members Attachment E.docx 02/03/2022
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
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