Patient Safety Organization Certification Forms and Patient Safety Confidentiality Complaint Form

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form Form #1 Patient Safety Confidentiality Complaint Form	Form and Instruction	Modified	Available
Form Form #3 Information Form - Revised	Form and Instruction	Modified	Available
Form Form #2 Two Bona Fide Contracts Requirement Form	Form and Instruction	Modified	Available
Form Form #5 Disclosure Form - Revised	Form and Instruction	Modified	Repair queued
Form Form #6 Certification for Continued Listing Form	Form and Instruction	Modified	Available
Form Form #4 Patient Safety Organization Certification for Initial Listing Form	Form and Instruction	Modified	Available
Attachment B -- PSO Form 10-21-2010.doc	Supplementary Document	Uploaded 2010-10-26	Repair queued
Attachment A -- Common Formats Details 10-21-2010.docx	Supplementary Document	Uploaded 2010-10-26	Available
PSO Memo 10-21-2010.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2010-10-26	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
186804	Patient Safety Confidentiality Complaint Form	Form and Instruction	Modified
186803	Information Form - Revised	Form and Instruction	Modified
186802	Two Bona Fide Contracts Requirement Form	Form and Instruction	Modified
186801	Disclosure Form - Revised	Form and Instruction	Modified
186800	Certification for Continued Listing Form	Form and Instruction	Modified
186799	Patient Safety Organization Certification for Initial Listing Form	Form and Instruction	Modified

ICR Details

OMB Control No: 0935-0143	ICR Reference No: 201011-0935-003
Status: Historical Active	Previous ICR Reference No: 200904-0935-001
Agency/Subagency: HHS/AHRQ	Agency Tracking No:
Title: Patient Safety Organization Certification Forms and Patient Safety Confidentiality Complaint Form
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 12/09/2010
	Date Received in OIRA: 11/24/2010
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2011	08/31/2011	08/31/2011
Responses	183	0	183
Time Burden (Hours)	77	0	77
Cost Burden (Dollars)	0	0	0

---

Abstract: The Patient Safety and Quality Improvement Act of 2005 (hereafter the Patient Safety Act, see Attachment A-2), signed into law on July 29, 2005, was enacted in response to growing concern about patient safety in the United States and the Institute of Medicine's 1999 report, To Err is Human: Building a Safer Health System. The goal of the statute is to improve patient safety by providing an incentive for health care providers to work voluntarily with experts in patient safety to reduce risks and hazards to the safety and quality of patient care. When specific statutory requirements are met by organizations seeking to offer expert analytic services regarding patient safety, the information collected and the analyses and deliberations regarding the information, receive Federal confidentiality and privilege protections under this legislation. The Secretary of the Department of Health and Human Services delegated authority to the Director of the Office for Civil Rights (OCR) to enforce the confidentiality protections of the patient safety legislation and delegated authority to the Director of the Agency for Healthcare Research and Quality (AHRQ) to implement and administer the rest of the statute's provisions (Federal Register, Vol. 71, No. 95, May 17, 2006, p. 28701-2).

---

Authorizing Statute(s): US Code: 42 USC 299 Name of Law: Healthcare Research and Quality Act of 1999
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
0919-AA01	Final or interim final rulemaking	73 FR 8112	02/12/2008

---

Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 6

table that charts list of burden

IC Title	Form No.	Form Name
Patient Safety Organization Certification for Initial Listing Form	Form #4	Patient Safety Organization Certification for Initial Listing Form
Disclosure Form - Revised	Form #5	Disclosure Statement Form
Certification for Continued Listing Form	Form #6	Certification for Continued Listing Form
Patient Safety Confidentiality Complaint Form	Form #1	Patient Safety Confidentiality Complaint Form
Two Bona Fide Contracts Requirement Form	Form #2	Two Bona Fide Contracts Requirement Form
Information Form - Revised	Form #3	Information Form

---

ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	183	183	0	0	0	0
Annual Time Burden (Hours)	77	77	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

---

Annual Cost to Federal Government: $15,000

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  No

---

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 11/24/2010

---