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

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 8 Attachment J: PSO Voluntary Relinquishment Form	Form and Instruction	Modified	Available
Form 8 Attachment L: PSO Voluntary Relinquishment Form	Form and Instruction	Modified	Repair queued
Form Form 6 Attachment H: PSO Change of Listing Information	Form and Instruction	Modified	Available
Form Form 6 Attachment J: PSO Change of Listing Information	Form and Instruction	Modified	Repair queued
Form Form #7 Attachment I: OCR Patient Safety Confidentiality Complaint Form	Form and Instruction	Modified	Available
Form Form #7 Attachment K: OCR Patient Safety Confidentiality Complaint Form	Form and Instruction	Modified	Repair queued
Form Form #1 Attachment C: PSO Certification for Initial Listing Form	Form and Instruction	Modified	Available
Form Form #1 Patient Safety Organization Certification for Initial Listing Form	Form and Instruction	Modified	Available
Form Form #5 Attachment G: PSO Profile Form	Form and Instruction	Modified	Available
Form Form #5 Information Form - Revised	Form and Instruction	Modified	Repair queued
Form Form #3 Attachment E: PSO Two Bona Fide Contracts Requirement Form	Form and Instruction	Modified	Available
Form Form #3 Two Bona Fide Contracts Requirement Form	Form and Instruction	Modified	Repair queued
Form Form #4 Attachment F: PSO Disclosure Statement Form	Form and Instruction	Modified	Available
Form Form #4 Disclosure Form - Revised	Form and Instruction	Modified	Available
Form Form #2 Attachment D: PSO Certification for Continued Listing Form	Form and Instruction	Modified	Available
Form Form #2 Certification for Continued Listing Form	Form and Instruction	Modified	Available
Form Form #9 Attachment K: Common Formats Details	Form and Instruction	Modified	Available
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	Available
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 ID	Collection	Type	Status	Form
231738	Attachment L: PSO Voluntary Relinquishment Form	Form and Instruction	Modified	Attachment J: PSO Voluntary Relinquishment Form
231738	Attachment L: PSO Voluntary Relinquishment Form	Form and Instruction	Modified
213835	Attachment J: PSO Change of Listing Information	Form and Instruction	Modified	Attachment H: PSO Change of Listing Information
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	Attachment I: OCR Patient Safety Confidentiality Complaint Form
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	Attachment C: PSO Certification for Initial Listing Form
186804	Patient Safety Organization Certification for Initial Listing Form	Form and Instruction	Modified
186803	Information Form - Revised	Form and Instruction	Modified	Attachment G: PSO Profile Form
186803	Information Form - Revised	Form and Instruction	Modified
186802	Two Bona Fide Contracts Requirement Form	Form and Instruction	Modified	Attachment E: PSO Two Bona Fide Contracts Requirement Form
186802	Two Bona Fide Contracts Requirement Form	Form and Instruction	Modified
186801	Disclosure Form - Revised	Form and Instruction	Modified	Attachment F: PSO Disclosure Statement Form
186801	Disclosure Form - Revised	Form and Instruction	Modified
186800	Certification for Continued Listing Form	Form and Instruction	Modified	Attachment D: PSO Certification for Continued Listing Form
186800	Certification for Continued Listing Form	Form and Instruction	Modified
186799	Common Formats	Form and Instruction	Modified	Attachment K: Common Formats Details
186799	Common Formats	Form and Instruction	Modified

ICR Details

OMB Control No: 0935-0143	ICR Reference No: 202107-0935-005
Status: Historical Active	Previous ICR Reference No: 201806-0935-001
Agency/Subagency: HHS/AHRQ	Agency Tracking No:
Title: Patient Safety Organization Certification for Initial Listing and Related Forms, Patient Safety Confidentiality Complaint Form, and Common Formats
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 09/16/2021
Retrieve Notice of Action (NOA)	Date Received in OIRA: 08/04/2021
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2024	36 Months From Approved	11/30/2021
Responses	1,236	0	1,219
Time Burden (Hours)	100,796	0	100,725
Cost Burden (Dollars)	0	0	0

---

Abstract: The Patient Safety and Quality Improvement Act of 2005 (hereafter the Patient Safety Act), 42 U.S.C. 299b-21 to 299b-26, 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. The Patient Safety Act signifies the Federal Government's commitment to fostering a culture of patient safety among health care providers; it offers a mechanism for creating an environment in which the causes of risks and hazards to patient safety can be thoroughly and honestly examined and discussed without fear of penalties and liabilities. It provides for the voluntary formation of Patient Safety Organizations (PSOs) that can collect, aggregate, and analyze confidential information reported voluntarily by health care providers. By analyzing substantial amounts of patient safety event information across multiple institutions, PSOs will be able to identify patterns of failures and propose measures to eliminate or reduce patient safety risks and hazards.

---

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:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 26036	05/12/2021
30-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 41036	07/30/2021
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 9

table that charts list of burden

IC Title	Form No.	Form Name
Attachment J: PSO Change of Listing Information	Form 6	Attachment H: PSO Change of Listing Information
Attachment K: OCR Patient Safety Confidentiality Complaint Form	Form #7	Attachment I: OCR Patient Safety Confidentiality Complaint Form
Attachment L: PSO Voluntary Relinquishment Form	8	Attachment J: PSO Voluntary Relinquishment Form
Certification for Continued Listing Form	Form #2	Attachment D: PSO Certification for Continued Listing Form
Common Formats	Form #9	Attachment K: Common Formats Details
Disclosure Form - Revised	Form #4	Attachment F: PSO Disclosure Statement Form
Information Form - Revised	Form #5	Attachment G: PSO Profile Form
Patient Safety Organization Certification for Initial Listing Form	Form #1	Attachment C: PSO Certification for Initial Listing Form
Two Bona Fide Contracts Requirement Form	Form #3	Attachment E: PSO Two Bona Fide Contracts Requirement 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	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

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: The previous information collection request (ICR) included an estimate of 100,724.91 total burden hours for the Common Formats and the following forms: PSO Certification for Initial Listing Form, PSO Certification for Continued Listing Form, PSO Two Bona Fide Contracts Requirement Form, PSO Disclosure Statement Form, PSO Profile Form, PSO Change of Listing Form, the OCR Patient Safety Confidentiality Form, and the PSO Voluntary Relinquishment Form. The estimated burden hours for the current ICR are 100,795.83 that represent an increase of 70.92 hours. For this submission, the burden of the forms remains unchanged. A few minor edits for clarity are being made to some of the existing forms which have not affected the burden estimates. The increase of 70.92 burden hours is attributed to the changes in the number of respondents for the PSO forms that are described below.

---

Annual Cost to Federal Government: $2,047,360

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

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     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? No

---

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: 08/04/2021

---