Attachment K: OCR Patient Safety Confidentiality Complaint Form

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⚠️ Notice: This information collection may be referencing outdated material.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 #7 Attachment K: OCR Patient Safety Confidentiality Complaint Form Form and Instruction
Form #7 Attachment I: OCR Patient Safety Confidentiality Complai pscomplaintform.pdf Form and Instruction
Form #7 Attachment I: OCR Patient Safety Confidentiality Complai pscomplaintform.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Attachment K: OCR Patient Safety Confidentiality Complaint Form	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 #7	Attachment I: OCR Patient Safety Confidentiality Complaint Form	pscomplaintform.pdf		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1	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: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	1	1
Annual IC Time Burden (Hours)	0	0
Annual IC Cost Burden (Dollars)	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.