Patient Safety Organization Certification for Initial Listing and Related Forms, Patient Safety Confidentiality Complaint Form, and Common Formats

Forms and Documents

Document	Type	Status	Availability
Form 8 OCR Complaint Consent Form	Form and Instruction	Unchanged	Available
Form 8 Attachment I_OCR Complaint Consent Form	Form and Instruction	Unchanged	Repair queued
Form Form 7 PSO Request for Voluntary Relinquishment	Form and Instruction	Unchanged	Available
Form Form 7 Attachment J_PSO Voluntary Relinquishment Form	Form and Instruction	Unchanged	Repair queued
Form Form 6 PSO Change of Listing Information	Form and Instruction	Unchanged	Available
Form Form 6 Attachment H_PSO Change of Listing Information	Form and Instruction	Unchanged	Available
Form Form 1 PSO Certification for Initial Listing Form	Form and Instruction	Unchanged	Repair queued
Form Form 1 Attachment C_Patient Safety Organization Certification for Initial Listing Form	Form and Instruction	Unchanged	Repair queued
Form Form 5 PSO profile name	Form and Instruction	Modified	Available
Form Form 5 Attachment G_PSO Profile Form	Form and Instruction	Modified	Repair queued
Form Form 3 PSO Two Bona Fide Contracts Requirement Form	Form and Instruction	Unchanged	Repair queued
Form Form 3 Attachment E_PSO Two Bona Fide Contracts Requirement Form	Form and Instruction	Unchanged	Repair queued
Form Form 4 PSO Disclosure Statement	Form and Instruction	Unchanged	Available
Form Form 4 Attachment F_PSO Disclosure Statement Form	Form and Instruction	Unchanged	Repair queued
Form Form 2 PSO Certification for Continued Listing Form	Form and Instruction	Unchanged	Available
Form Form 2 Attachment D_PSO Certification for Continued Listing Form	Form and Instruction	Unchanged	Repair queued
Form Form 9 AHRQ Common Formats	Form and Instruction	Unchanged	Repair queued
Form Form 9 Attachment K_AHRQ Common Formats	Form and Instruction	Unchanged	Repair queued
NonSub Change - Update to AHRQ PSO Profile Form.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2025-12-04	Repair queued
NonSub Change - Update to AHRQ PSO Profile Form.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2025-12-04	Repair queued
Attachment B_Patient Safety and Quality Improvement Rule-2008.pdf	Supplementary Document	Uploaded 2024-10-16	Available
Attachment B_Patient Safety and Quality Improvement Rule-2008.pdf	Supplementary Document	Uploaded 2024-10-16	Repair queued
Attachment A_Patient Safety and Quality Improvement Act of 2005.pdf	Supplementary Document	Uploaded 2024-10-16	Repair queued
Attachment A_Patient Safety and Quality Improvement Act of 2005.pdf	Supplementary Document	Uploaded 2024-10-16	Repair queued
Supporting Statement Part A_PSO Certification and Related Forms 0934-0143.docx	Supporting Statement A	Uploaded 2024-10-11	Available
Supporting Statement Part A_PSO Certification and Related Forms 0934-0143.docx	Supporting Statement A	Uploaded 2024-10-11	Repair queued

IC Document Collections

IC ID	Collection	Type	Status	Form
276597	Attachment I_OCR Complaint Consent Form	Form and Instruction	Unchanged	OCR Complaint Consent Form
276597	Attachment I_OCR Complaint Consent Form	Form and Instruction	Unchanged
231738	Attachment J_PSO Voluntary Relinquishment Form	Form and Instruction	Unchanged	PSO Request for Voluntary Relinquishment
231738	Attachment J_PSO Voluntary Relinquishment Form	Form and Instruction	Unchanged
213835	Attachment H_PSO Change of Listing Information	Form and Instruction	Unchanged	PSO Change of Listing Information
213835	Attachment H_PSO Change of Listing Information	Form and Instruction	Unchanged
186804	Attachment C_Patient Safety Organization Certification for Initial Listing Form	Form and Instruction	Unchanged	PSO Certification for Initial Listing Form
186804	Attachment C_Patient Safety Organization Certification for Initial Listing Form	Form and Instruction	Unchanged
186803	Attachment G_PSO Profile Form	Form and Instruction	Modified	PSO profile name
186803	Attachment G_PSO Profile Form	Form and Instruction	Modified
186802	Attachment E_PSO Two Bona Fide Contracts Requirement Form	Form and Instruction	Unchanged	PSO Two Bona Fide Contracts Requirement Form
186802	Attachment E_PSO Two Bona Fide Contracts Requirement Form	Form and Instruction	Unchanged
186801	Attachment F_PSO Disclosure Statement Form	Form and Instruction	Unchanged	PSO Disclosure Statement
186801	Attachment F_PSO Disclosure Statement Form	Form and Instruction	Unchanged
186800	Attachment D_PSO Certification for Continued Listing Form	Form and Instruction	Unchanged	PSO Certification for Continued Listing Form
186800	Attachment D_PSO Certification for Continued Listing Form	Form and Instruction	Unchanged
186799	Attachment K_AHRQ Common Formats	Form and Instruction	Unchanged	AHRQ Common Formats
186799	Attachment K_AHRQ Common Formats	Form and Instruction	Unchanged

ICR Details

OMB Control No: 0935-0143	ICR Reference No: 202512-0935-001
Status: Active	Previous ICR Reference No: 202410-0935-002
Agency/Subagency: HHS/AHRQ	Agency Tracking No:
Title: Patient Safety Organization Certification for Initial Listing and Related Forms, Patient Safety Confidentiality Complaint Form, and Common Formats
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 12/11/2025
Retrieve Notice of Action (NOA)	Date Received in OIRA: 12/08/2025
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2028	07/31/2028	07/31/2028
Responses	1,240	0	1,240
Time Burden (Hours)	100,811	0	100,811
Cost Burden (Dollars)	0	0	0

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Abstract: The Patient Safety and Quality Improvement Act of 2005 (hereafter the Patient Safety Act), 42 U.S.C. 299b-21 to 299b-26, was enacted in response to growing concern about patient safety in the United States and the Institute of Medicine's 1999 report, To Err is Human: Building a Safer Health System. The goal of the statute is to improve patient safety by providing an incentive for health care providers to work voluntarily with experts in patient safety to reduce risks and hazards to the safety and quality of patient care. The Patient Safety Act signifies the Federal Government's commitment to fostering a culture of patient safety among health care providers; it offers a mechanism for creating an environment in which the causes of risks and hazards to patient safety can be thoroughly and honestly examined and discussed without fear of penalties and liabilities. It provides for the voluntary formation of Patient Safety Organizations (PSOs) that can collect, aggregate, and analyze confidential information reported voluntarily by health care providers. By analyzing substantial amounts of patient safety event information across multiple institutions, PSOs will be able to identify patterns of failures and propose measures to eliminate or reduce patient safety risks and hazards.

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Authorizing Statute(s): US Code: 42 USC 299 Name of Law: Healthcare Research and Quality Act of 1999
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	89 FR 65629	08/12/2024
30-day Notice:	Federal Register Citation:	Citation Date:
	89 FR 83499	10/16/2024
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 9

IC Title	Form No.	Form Name
Attachment C_Patient Safety Organization Certification for Initial Listing Form	Form 1	PSO Certification for Initial Listing Form
Attachment D_PSO Certification for Continued Listing Form	Form 2	PSO Certification for Continued Listing Form
Attachment E_PSO Two Bona Fide Contracts Requirement Form	Form 3	PSO Two Bona Fide Contracts Requirement Form
Attachment F_PSO Disclosure Statement Form	Form 4	PSO Disclosure Statement
Attachment G_PSO Profile Form	Form 5	PSO profile name
Attachment H_PSO Change of Listing Information	Form 6	PSO Change of Listing Information
Attachment I_OCR Complaint Consent Form	8	OCR Complaint Consent Form
Attachment J_PSO Voluntary Relinquishment Form	Form 7	PSO Request for Voluntary Relinquishment
Attachment K_AHRQ Common Formats	Form 9	AHRQ Common Formats

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	1,240	1,240	0	0	0	0
Annual Time Burden (Hours)	100,811	100,811	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $1,373,675

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 12/08/2025

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