Attachment J: PSO Change of Listing Information

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⚠️ Notice: This information collection may be referencing outdated material.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 6 Attachment J: PSO Change of Listing Information Form and Instruction
Form 6 Attachment H: PSO Change of Listing Information Attachment.J.PSO_Change of listing information form_AHRQ.11.2017.docx www.pso.ahrq.gov Form and Instruction
Form 6 Attachment H: PSO Change of Listing Information Attachment.J.PSO_Change of listing information form_AHRQ.11.2017.docx www.pso.ahrq.gov Form and Instruction

Information Collection (IC) Details

IC Title:	Attachment J: PSO Change of Listing Information	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 6	Attachment H: PSO Change of Listing Information	Attachment.J.PSO_Change of listing information form_AHRQ.11.2017.docx	www.pso.ahrq.gov	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 54	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	54	-7	61
Annual IC Time Burden (Hours)	5	0	5
Annual IC Cost Burden (Dollars)	0	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.