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

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.