Information Collection Request

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

ICR 202107-0935-005 · OMB 0935-0143 · Received in OIRA

Forms and Documents

Forms and supporting documents for this ICR
DocumentTypeStatusAvailability
Form 8 Attachment L: PSO Voluntary Relinquishment Form Form and Instruction Modified Missing upstream
Form Form 6 Attachment J: PSO Change of Listing Information Form and Instruction Modified Repair queued
Form Form #7 Attachment K: OCR Patient Safety Confidentiality Complaint Form Form and Instruction Modified Repair queued
Form Form #1 Patient Safety Organization Certification for Initial Listing Form Form and Instruction Modified Repair queued
Form Form #5 Information Form - Revised Form and Instruction Modified Repair queued
Form Form #3 Two Bona Fide Contracts Requirement Form Form and Instruction Modified Repair queued
Form Form #4 Disclosure Form - Revised Form and Instruction Modified Repair queued
Form Form #2 Certification for Continued Listing Form Form and Instruction Modified Repair queued
Form Form #9 Common Formats Form and Instruction Modified Repair queued
Attachment.D.Patient Safety Act.PSWP.Providers.External.Obligations.AHRQ.11.2017.pdf Supplementary Document Uploaded 2018-06-06 Repair queued
Attachment.C.Guidance Regarding Patient Safety Organizations’ Reporting FDA.Obligations.AHRQ.11.2017.pdf Supplementary Document Uploaded 2018-08-30 Repair queued
Patient Safety and Quality Improvement_ Final Rule.pdf Supplementary Document Uploaded 2021-08-02 Repair queued
Patient Safety Act PDF.pdf Supplementary Document Uploaded 2021-08-02 Repair queued
PSO OMB.2021.Supporting Statement Part A Clean.docx Supporting Statement A Uploaded 2021-08-02 Repair queued

IC Document Collections

Information collection document groups
IC IDCollectionTypeStatusForm
231738 Attachment L: PSO Voluntary Relinquishment Form Form and Instruction Modified
213835 Attachment J: PSO Change of Listing Information Form and Instruction Modified
198467 Attachment K: OCR Patient Safety Confidentiality Complaint Form Form and Instruction Modified
186804 Patient Safety Organization Certification for Initial Listing 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 Common Formats Form and Instruction Modified

ICR Details

Reginfo record details
table that charts list comparision
  Requested Previously Approved
36 Months From Approved 11/30/2021
1,236 1,219
100,796 100,725
0 0





table that charts list of burden
  Total Request 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 1,236 1,219 0 17 0 0
Annual Time Burden (Hours) 100,796 100,725 0 71 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0


Reginfo record details
  No