Agency Information Collection Activities: Proposed Collection

DEPARTMENT OF DEFENSE

Department of the Air Force

Agency Information Collection Activities: Proposed Collection

AGENCY: Air Force Medical Operations Agency, DoD.

In compliance with Section 3506(c)(2)(A) of the Paperwork Reduction

Act of 1995, the Air Force Medical Operations Agency, Clinical Quality

Management Division, AFMOA/SGOC, announces the proposed reinstatement

and the initiation of a public information collection and seeks public

comment on the provisions thereof. Comments are invited on: (a) whether

the proposed collection of information is necessary for the proper

performance of the functions of the Agency, including whether the

information shall have practical utility; (b) the accuracy of the

Agency's estimate of the burden of the proposed information collection;

(c) ways to enhance the quality, utility, and clarity of the

information to be collected; and (d) ways to minimize the burden of the

information collection on respondents, including through the use of

automated collection techniques or other forms of information

technology.

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DATES: Consideration will be given to all comments received on or

before March 8, 1999.

ADDRESSES: Written comments and recommendations on the proposed

information collection should be sent to 110 Luke Avenue, Room 405,

Bolling AFB, DC 20332-7050, ATTN: Maj Lynn Poppino.

FOR FURTHER INFORMATION CONTACT: To request more information on this

proposed information collection or to obtain a copy of the proposal and

associated collection instruments, please write to the above address,

or call AFMOA/SGOC at (202) 767-4077.

Title, Associated Forms, and OMB Number: Medical Treatment Facility

Incident Statement, AF Form 765, OMB Number 0701-0135

Needs and Uses: The form is used by respondents (hospital

employees, including non-governmental personnel and contractors) to

report specific incidents that may have resulted in injury. It is not

filed in a patient's record, but is kept by the medical treatment

facility (MTF) Quality Service/Risk Manager until appropriate actions

are completed to analyze the incident and determine whether corrective

action is necessary to avoid repeat incidents. After completion, and

corrective action if required, the form is retained for one year and

then destroyed. Information recorded on the form is concise statements

of fact. If the information is not collected as needed, MTFs will lose

the opportunity to identify potential risks in the facilities. Possible

outcomes for failure to identify risks are medical malpractice, patient

injury or death, unnecessary financial expenditure, and poor public

perception of the MTF.

Affected Public: All individuals in Air Force Medical Treatment

Facilities, to include patients, visitors, contractors, civilian, and

military staff members.

Annual Burden Hours: 1,056.

Number of Respondents: 13,200.

Responses per Respondent: 1.

Average Burden per Respondent: 5 minutes.

Frequency: In the event of an incident resulting in injury or

possible injury.

SUPPLEMENTARY INFORMATION: Summary of Information Collection.

Carolyn A. Lunsford,

Air Force Federal Register Liaison Officer.

[FR Doc. 99-212 Filed 1-5-99; 8:45 am]

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