Form 8 Form 8 Attachment I: PSO Change of Listing Information

Form Approved

OMB No.: 0935-0143

Exp. Date: ??/??/????

PATIENT SAFETY ORGANIZATION: CHANGE OF LISTING INFORMATION

The Patient Safety and Quality Improvement Act of 2005 (Patient Safety Act), and its implementing regulations in 42 CFR Part 3 (Patient Safety Rule), authorize the creation of Patient Safety Organizations (PSOs). The Agency for Healthcare Research and Quality (AHRQ), of the Department of Health and Human Services (HHS), administers the provisions of the Patient Safety Act and Patient Safety Rule dealing with PSO operations. Information related to PSOs is available on AHRQ's PSO Web site at www.pso.ahrq.gov.Please provide any revisions or additions to the listing information, including a brief explanation. As required in the Patient Safety Rule, section 3.102(a)(vi), a PSO must promptly notify the Secretary during its period of listing if there have been any changes in the accuracy of the information submitted for listing, along with the pertinent changes.

Please note that certain changes may affect your PSO’s attestations in support of the current certification for listing (e.g., parent organization added). The PSO Office will contact you for clarification if necessary.

Please submit this form to AHRQ’s PSO Office via e-mail, at [email protected]. To submit a hard copy, please send to: PSO Office, AHRQ, 540 Gaither Road, Rockville, MD 20850.

PSO Number: _____________ Current PSO Name:__________________________________________________ * * * Only fill out the information that has changed * * *
PSO Entity Information
Name
Web site
Street Address
Mailing Address
Telephone	Fax
Explanation of Change:
PSO Parent Organization Information
Name
Web site
Street Address
Telephone	Fax
Explanation of Change:
Authorized Official Information
Name
Title
Email
Telephone	Fax
Explanation of Change:
Primary Point of Contact Information
Name
Title
Email
Telephone	Fax
Explanation of Change:

***This form must be signed and dated by the authorized official on record with AHRQ.

Authorized Official Signature:_______________________________________________________________

Date:__________________________________________________________________________________

This completed form is considered public information.

Burden Statement

Public reporting burden for the collection of information is estimated to average 5 minutes per response. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: AHRQ Reports Clearance Officer, Attention: PRA, Paperwork Reduction Project (0935-0143), AHRQ, 540 Gaither Road, Room #5036, Rockville, MD 20850.

 

Attachment I: PSO Change of Listing Information 3