Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Attachment H: Survey of Patient Safety Culture – HSOPS Modified 13334 3334 0 Form and Instruction 1 Attachment H: Survey of Patient Safety Culture – HSOPS
Attachment I: Survey of Patient Safety Culture – NHSOPS Unchanged 5000 1250 0 Form and Instruction 2 2,500
Attachment J - Subsequent data pull for 10% of units New 81 20 0 Form and Instruction 9.5 Attachment J - Subsequent data pull for 10% of units
Attachment J: Clinical Outcomes Data for ICU/Non-ICU Unchanged 267 935 0 Form and Instruction 9 Attachment J: Clinical Outcomes Data for ICU/Non-ICU
Attachment J: Clinical Outcomes Data for ICU/Non-ICU Unchanged 1602 801 0 Form and Instruction 9 Attachment J: Clinical Outcomes Data for ICU/Non-ICU
Attachment J: Clinical Outcomes Data for ICU/Non-ICU Unchanged 27 14 0 Form and Instruction 9 Attachment J: Clinical Outcomes Data for ICU/Non-ICU
Attachment J: Clinical Outcomes Data for ICU/Non-ICU Unchanged 27 135 0 Form and Instruction 9 Attachment J: Clinical Outcomes Data for ICU/Non-ICU
Attachment K: Clinical Outcomes Data for Surgical Services Modified 50 50 0 Form and Instruction 10 Attachment K: Clinical Outcomes Data for Surgical Services
Attachment K: Clinical Outcomes Data for Surgical Services Modified 300 150 0 Form and Instruction 10 Attachment K: Clinical Outcomes Data for Surgical Services
Attachment L: Clinical Outcomes Data for LTC Modified 100 600 0 Form and Instruction 11 Attachment L: Clinical Outcomes Data for LTC
Attachment L: Clinical Outcomes Data for LTC Modified 1800 1350 0 Form and Instruction 11 Attachment L: Clinical Outcomes Data for LTC
Attachment Q: Survey of Patient Safety Culture-HSOPS V.2 New 5000 1050 0 Form and Instruction 17 Attachment Q: Survey of Patient Safety Culture—HSOPS V.2
Gap Analysis Unchanged 934 934 0 Form and Instruction 3 Attachment B: ICU/Non-ICU Gap Analysis
Form and Instruction 4 Attachment C: Surgical Services Gap Analysis
Form and Instruction 5 Attachment D: LTC Gap Analysis
TEAM CHECK-UP TOOL – Long-Term Care (LTC) Unchanged 1800 306 0 Form and Instruction 8 Attachment G: LTC Team Checkup Tool
Team Checkup Tool Unchanged 6606 1123 0 Form and Instruction 6 Attachment E: ICU/Non-ICU Team Checkup Tool
Form and Instruction 7 Attachment F: Surgical Services Team Checkup Tool
Total burden requested under this ICR: 36928 12052 0  
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