Form 6 Form 6 PSO Change of Listing Information

Clean version 9-26-2024

Form Approved
OMB No. 0935-0143
Exp. Date XX/XX/XXXX

PATIENT SAFETY ORGANIZATION: CHANGE OF LISTING INFORMATION

The Patient Safety and Quality Improvement Act of 2005 (Patient Safety Act) authorizes the creation of Patient Safety Organizations (PSOs). The Agency for Healthcare Research and Quality (AHRQ), of the Department of Health and Human Services (HHS), administers the provisions of the Patient Safety Act and Patient Safety Rule dealing with PSO operations. Information related to PSOs is available on AHRQ's PSO website at www.pso.ahrq.gov.

As required by section 3.102(a)(vi) of the Patient Safety Rule, a PSO must promptly notify the Secretary of HHS during its period of listing if there have been any changes in the accuracy of the information submitted for listing, along with the pertinent changes.

Instructions: Please provide the PSO’s number and current PSO name; complete only the sections(s) below that apply to the change(s) in listing information that are the subject of this notification; and, have the completed form signed by the PSO’s Authorized Official. Please note that certain changes may affect your PSO’s attestations in support of the current certification for listing (e.g., if a parent organization is added). The PSO Office will contact you for clarification if necessary.

Please submit this form to AHRQ's PSO Office via e-mail, at [email protected]. To submit a hard copy, please send to: PSO Office, AHRQ, 5600 Fishers Lane, MS 06N100B, Rockville, MD 20857.

CURRENT PSO NUMBER AND NAME
PSO Number _____________ PSO Name__________________________________________________
***Fill out only what has changed and leave the rest blank.***
Changes to PSO Entity Information
Name
Alternate legal name (if applicable)
Website
Street Address
Mailing Address
Phone	Extension (if applicable)
Reason for change(s)
Changes to Existing PSO Parent Organization(s) Information NOTE: If you have changes to what entity is the PSO’s parent organization (e.g., adding or removing a parent organization), please contact AHRQ at [email protected].
Name
Alternate legal name (if applicable)
Website
Street Address
Phone	Extension (if applicable)
Reason for change(s)
Changes to Authorized Official (AO) Information
Name
Title
Organization (if different from PSO)
Email
Phone	Extension (if applicable)
Reason for change(s)
Changes to Alternative Primary Point of Contact Information (if Primary Point of Contact is different from the AO) NOTE: This person will be copied on all communications from AHRQ and be shown as the Point of Contact on the Listed PSOs page. They cannot make attestations on behalf of the PSO.
Name
Title
Organization (if different from PSO)
Email
Phone	Extension (if applicable)
Reason for change(s)

***This form must be signed and dated by the Authorized Official on record with AHRQ.***

Name _______________________________________________________________

Signature _______________________________________________________________

Date__________________________________________________________________________________

This completed form is considered public information.

Burden Statement

This survey is authorized under 42 U.S.C. 299a. This information collection is voluntary and the confidentiality of your responses to this survey is protected by Sections 944(c) and 308(d) of the Public Health Service Act [42 U.S.C. 299c-3(c) and 42 U.S.C. 242m(d)]. Information that could identify you will not be disclosed unless you have consented to that disclosure. Public reporting burden for this collection of information is estimated to average 5 minutes per response, the estimated time required to complete the survey. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The data provided will help AHRQ’s mission to produce evidence to make health care safer, higher quality, more accessible, equitable, and affordable. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (OMB control number 0935-0143) AHRQ, 5600 Fishers Lane, Room #07W42, Rockville, MD 20857, or by email to [email protected].