Form #5 Form #5 Information Form 10/2/2008

PATIENT SAFETY ORGANIZATION INFORMATION FORM

Completion of this form provides information to the Department of Health and Human Services on the types of healthcare settings with which Patient Safety Organizations are working to conduct patient safety activities. This form is designed to collect data to report aggregate statistics on the impact of the Patient Safety and Quality Improvement Act of 2005 (Act); no PSO-specific data will be released. Please report this information by February 15^th of the year following that to which the information pertains. If more convenient, the PSO may provide requested information in a word processed document or spreadsheet. Regardless, the PSO must complete and submit part 3 of this form. Calendar year to which information pertains is _____.

NAME – PATIENT SAFETY ORGANIZATION:

Number

1 (a). During calendar year _____, with how many provider organizations did the PSO have a contract or agreement for

services pursuant to the Act? Count each contract or agreement only once regardless of how many facilities each

contract or agreement covered. _______

1 (b). From how many of these provider organizations did the PSO receive PSWP at any time during calendar year _____? _______

1 (c). During calendar year _____, from how many provider organizations with which the PSO did not have a contract or

agreement to receive PSWP did it receive PSWP? If none, enter “none.” ________

2 (a). For purposes of completing the following table, please count each discrete facility covered by a contract or agreement to receive PSWP

at any time during calendar year _____. For example, if the PSO had a contract or agreement to receive PSWP from a chain of hospitals, count each hospital. Assign each discrete facility to only one of the following categories.

2 (b). For each facility counted, provide the first 3 digits of its Zipcode. If there are 2 facilities in a category with the same first 3-digit Zipcode,

for example, enter that Zipcode 2 times.

Inpatient Setting	2a Number of facilities	2b Zipcodes of facilities
Inpatient facilities:	- -	- -
General (acute care) hospital	- -	- -
less than 100 beds
100 – 299 beds
300 or more beds
Specialty or other hospital	- -	- -
Less than 100 beds
100 – 299 beds
300 or more beds
Skilled or other nursing home/facility
Assisted living or other residential care facility
Other inpatient care facility, specify __________________________________________
Ambulatory Health Care Setting (fixed or mobile; free-standing or attached)	- -	- -
Licensed/certified practitioner’s office (doctor, dentist, psychologist, physiotherapist, etc.); includes specialty practice, e.g., osteoporosis center, urgent care center
Health center, clinic, or group practice (6 or more practitioners in a formal affiliation who share income, expenses, equipment, and support staff); includes specialty clinic, e.g., free-standing emergency department, imaging center, mental health center, women's clinic
Ambulatory surgical center
Medical or diagnostic laboratory; includes blood bank
Treatment facility, e.g., renal dialysis center
Other ambulatory care facility, specify ________________________________________
Other Health Care Setting	- -	- -
Ambulance or emergency medical services
Home health care agency
Retail pharmacy
Other health care setting, specify _____________________________________________
Unknown Type of Health Care Setting
TOTAL:		- -

3. To the best of my knowledge and belief, all data in this form are true and correct.

PSO Authorized Official Printed Name and Title: ___________________________________________________________

PSO Authorized Official Signature: ______________________________________________________________________

Telephone Number (including area code): _________________________________________________________________

Date: ______________________________________________________________________________________________