Form #5 Form #5 Information Form

Form Approved


OMB No. 0935-XXXX


Exp. Date XX/XX/20XX

PATIENT SAFETY ORGANIZATION INFORMATION FORM

Completion of this form is voluntary and 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 data for the year 2008. If more convenient, the PSO may provide requested data in a word processed document or spreadsheet. Regardless, the PSO must complete and submit part 3 of this form. Submit this form/data by February 15, 2009.

NAME – PATIENT SAFETY ORGANIZATION:

Number

1 (a). During 2008, 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 2008? _______

1 (c). During 2008, 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 2008. 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: ______________________________________________________________________________________________

Burden Statement

Public reporting burden for the collection of information on this complaint form is estimated to average 30 minutes per response, including the time for reviewing instructions, gathering the data needed and entering and reviewing the information on the completed complaint form. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: HHS/OS Reports Clearance Officer, Office of Information Resources Management, 200 Independence Ave. S.W., Room 531H, Washington, D.C. 20201