Disclosure Form - Revised

Patient Safety Organization Certification Forms and Patient Safety Confidentiality Complaint Form

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0935-0143 can be found here:

Documents and Forms

Document Name Document Type
Form Form #3 Disclosure Form - Revised Form and Instruction
Form #3 Disclosure Form 10/2/2008 DISCLOSURES REGARDING PSO RELATIONSHIPS WITH PROVIDERS_Interim Guidance_2Oct08.doc Form and Instruction

Information Collection (IC) Details

IC Title:	Disclosure Form - Revised	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	Form #3	Disclosure Form 10/2/2008	DISCLOSURES REGARDING PSO RELATIONSHIPS WITH PROVIDERS_Interim Guidance_2Oct08.doc		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 17	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	17	17
Annual IC Time Burden (Hours)	9	9
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.