Information Collection

Patient Safety Organization Certification for Initial Listing Form

IC 186804 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⚠️ Notice: This information collection may be referencing outdated material.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 #1 Patient Safety Organization Certification for Initial Listing Form	Form and Instruction
Form #1 Attachment C: PSO Certification for Initial Listing Form FINAL_PSO cert of initial listing_Final edits_06-10-2021.docx www.pso.ahrq.gov	Form and Instruction
Form #1 Attachment C: PSO Certification for Initial Listing Form FINAL_PSO cert of initial listing_Final edits_06-10-2021.docx www.pso.ahrq.gov	Form and Instruction

IC Title:

Patient Safety Organization Certification for Initial Listing Form

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 #1	Attachment C: PSO Certification for Initial Listing Form	FINAL_PSO cert of initial listing_Final edits_06-10-2021.docx	www.pso.ahrq.gov	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 10

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	10	-6	16
Annual IC Time Burden (Hours)	180	-108	288
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.