Information Collection

Information Form - Revised

IC 186803 under ICR 202107-0935-005 · OMB 0935-0143.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0935-0143 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Form #5 Information Form - Revised	Form and Instruction
Form #5 Attachment G: PSO Profile Form 2020 PSO Profile Form.pdf www.psoppc.org/web/patientsafety	Form and Instruction
Form #5 Attachment G: PSO Profile Form 2020 PSO Profile Form.pdf www.psoppc.org/web/patientsafety	Form and Instruction

IC Title:

Information Form - Revised

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	Form #5	Attachment G: PSO Profile Form	2020 PSO Profile Form.pdf	https://www.psoppc.org/web/patientsafety	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 72

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

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

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	72	2	70
Annual IC Time Burden (Hours)	216	6	210
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
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.