Disclosure Form - Revised

Patient Safety Organization Certification for Initial Listing and Related Forms, Patient Safety Confidentiality Complaint Form, and Common Formats

⚠️ Notice: This information collection may be referencing outdated material.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 #4 Disclosure Form - Revised Form and Instruction
Form #4 PSO Disclosure Statement Form Attachment.H.PSO_Disclosure.Statement form_AHRQ.11.2017.docx www.pso.ahrq.gov/forms/disclosure Form and Instruction

Information Collection (IC) Details

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

Is this a Common Form? No		IC Status: Modified

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 #4	PSO Disclosure Statement Form	Attachment.H.PSO_Disclosure.Statement form_AHRQ.11.2017.docx	https://www.pso.ahrq.gov/forms/disclosure	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 3	Number of Respondents for Small Entity: 0

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

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	3	1	2
Annual IC Time Burden (Hours)	9	3	6
Annual IC Cost Burden (Dollars)	0	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.