Form #3 Form #3 Information Form

Form Approved

OMB No. 0935-0143   

Exp. Date: 12/31/2009

PATIENT SAFETY ORGANIZATION INFORMATION FORM
Before completing this form, please review the requirements of the rule specified in 42 CFR Part 3, especially sections 3.102 (a), 3.102 (c), and 3.106. The rule implements the Patient Safety and Quality Improvement Act of 2005 (Patient Safety Act), which 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 dealing with PSO operations. The rule and other PSO-related information are available on AHRQ’s PSO Web site at www.pso.ahrq.gov. Completion of this form provides information to HHS on the types of health care settings with which PSOs are working to conduct patient safety activities. This form is designed to collect data to report aggregate statistics on the impact of the Patient Safety Act; no PSO-specific data will be released. Instructions: For purposes of completing the following information, please count each discrete facility covered by a contract or agreement to receive patient safety work product (PSWP) at any time during the above identified calendar year. For example, if the PSO had a contract or agreement to receive PSWP from a chain of hospitals, count each hospital. Assign each discrete facility to only one of the following categories. For each facility counted, provide the first three digits of its Zip code. If there are two or more facilities in a category with the same first three digit Zip code, enter that Zip code two or more times. Please report this information by February 15th of the year following that to which the information pertains. For example, data from calendar year 2009 should be reported by February 15, 2010. If more convenient, the PSO may provide requested information in an electronic document in the Word.DOC format, the Excel.XLS format, or text only format. Please submit this form to AHRQ’s PSO Office via email, if possible, at PSO@ahrq.hhs.gov. To submit a hard copy, please send to: PSO Office, AHRQ, 540 Gaither Road, Rockville, MD 20850.
PSO NAME: _____________________________________________________________________________________________________ AHRQ PSO ASSIGNED NUMBER:__________________________ CALENDAR YEAR FOR REPORT: ________________________
In this report year, with how many provider organizations did the PSO have a contract or agreement for services pursuant to the Patient Safety Act? Count each contract or agreement only once regardless of how many facilities each contract or agreement covered. From how many of these provider organizations did the PSO receive PSWP at any time during this report year? From how many provider organizations, with which the PSO did not have a contract or agreement to receive PSWP, did it receive PSWP in this report year? If none, enter “none”.			1. __________ 2. __________ 3. __________
	Number of facilities	Zip codes of facilities (first three digits)
Inpatient Setting
Inpatient facilities:	- -	- -
General (acute care) hospital	- -	- -
Less than 100 beds
100 – 299 beds
300 or more beds
Specialty or other hospital	- -	- -
Less than 100 beds
100 – 299 beds
300 or more beds
Skilled or other nursing home facility
Assisted living or other residential care facility
Other inpatient care facility, please specify: ________________________________________________
	Number of facilities	Zip codes of facilities (first three digits)
Ambulatory Health Care Setting (fixed or mobile; free-standing or attached)
Licensed/state-certified practitioner’s office (such as doctor, dentist, psychologist, physiotherapist, etc.) with five or fewer practitioners
Licensed/state-certified practitioner’s office (such as doctor, dentist, psychologist, physiotherapist, etc.) with six or more practitioners; includes community health center, group practice, clinic, etc. with six or more practitioners
Ambulatory surgical center
Independent laboratory, free-standing diagnostic or imaging center, tissue bank, etc.
Specialized treatment facility; includes renal dialysis center, chemotherapy center, etc.
Other ambulatory care facility, please specify: _________________________________________________
Other Health Care Setting
Ambulance, emergency medical technician, or paramedic services, etc.
Home health care; includes in-home, treatment services, hospice care, etc.
Retail pharmacy
Other health care setting, please specify: _________________________________________________
Unknown Type of Health Care Setting
Please specify: _____________________________________ Please specify: _____________________________________ Please specify: _____________________________________
Form completed by: ________________________________________________________________________________________________ Telephone Number: ________________________________________________________________________________________________ Date: ____________________________________________________________________________________________________________ This completed form is considered public information
Burden Statement Public reporting burden for the collection of information is estimated to average 30 minutes per response.  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.  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 (0935-0143), AHRQ, 540 Gaither Road, Room #5036, Rockville, MD 20850.

PSO Information Page 3 of 3