Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
1. Attachment A - Site Interest Form New 1060 106 0 Form and Instruction 1 Site Interest Form
10. Attachment K - Measure Dx Organizational Self-Assessment New 73 37 0 Form and Instruction 10 Measure Dx Data Collection Instrument
11. Attachment L - Measure Dx Declaration of Measurement Strategy New 73 6 0 Form and Instruction 11 Measure Dx Data Collection Instrument
12. Attachment M - Diagnostic Safety Event Report New 219 73 0 Form and Instruction 12 Site Data Submission Form
13. Omnibus Safety and Culture Survey New 987 329 0 Form and Instruction 13a Omnibus Survey of Diagnostic Safety Culture: Medical Offices
Form and Instruction 13b Omnibus Survey of Diagnostic Safety Culture: Hospitals
14. Attachment P - Calibrate Dx Survey New 1316 658 0 Form and Instruction 14 Calibrate Dx: Diagnostic Calibration Debrief Tool
15. Attachment Q - Clinical Self-Efficacy Survey New 658 33 0 Form and Instruction 15 Clinical Self-Efficacy for Diagnostic Decision-Making
16. Attachment R - Provider Characteristics Form New 986 16 0 Form and Instruction 16 Toolkit for Engaging Patients Provider Demographic Survey
17. Attachment S - Patient Toolkit Survey-Provider New 4930 164 0 Form and Instruction 17 Patient ToolKit Survey-Provider
18. Attachment T - Provider Interview Protocol New 50 38 0 Form and Instruction 18 Provider Interview Protocol
19. Attachment U - Patient Toolkit Survey - Patient New 62500 5208 0 Form and Instruction 19 Patient Survey
2. Attachment B - Site Information Form New 265 88 0 Form and Instruction 2 Site Information Form
20. Attachment V - Patient Interview Protocol New 50 38 0 Form and Instruction 20 Patient Interview Protocol
3. Attachment C - Safer Dx Checklist New 219 55 0 Form and Instruction 3 The Safer Dx Checklist: 10 High-Priority Practices for Diagnostic Excellence
4. Attachment D - Exit Interview Protocol for Attritor Sites New 69 12 0 Form and Instruction 4 Exit Interview Protocol for Attritor Sites
5. Diagnostic Safety Supplemental Set New 219 55 0 Form and Instruction 5a Medical Office Survey on Patient Safety
Form and Instruction 5b Hospital Survey on Patient Safety
6. Attachment G - Post-training Evaluation Form New 1350 68 0 Form and Instruction 6 Post-Training Evaluation Form
7. Attachment H - Post-Technical Assistance Evaluation Form New 4050 135 0 Form and Instruction 7 Post-Technical Assistance Evaluation Form
8. Attachment I - Clinical Sustainability Assessment Tool (CSAT) New 219 55 0 Form and Instruction 8 Clinical Sustainability Assessment Tool
9. Attachment J - Implementation Interviews Protocol New 876 876 0 Form and Instruction 9 Interview Protocol: Implementation Experience
Total burden requested under this ICR: 80169 8050 0  
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