Form 8 Attachment L: PSO Voluntary Relinquishment Form

Attachment L

Form Approved
OMB No. 0935-0143
Exp. Date ?????????

PATIENT SAFETY ORGANIZATION:

REQUEST FOR VOLUNTARY RELINQUISHMENT

The Patient Safety and Quality Improvement Act of 2005 (Patient Safety Act), and its implementing regulation authorize 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.

An entity is listed as a PSO when the Secretary accepts the entity’s certification submission and determines that it meets the applicable statutory and regulatory requirements. A PSO can be "delisted" by the Secretary if: (a) the PSO no longer meets the requirements of the Patient Safety Act and/or Patient Safety Rule; (b) the PSO’s three-year listing period expires; or (c) the PSO chooses to voluntarily relinquish its status as a PSO for any reason. Section 3.108(d) of the Patient Safety Rule states that when a PSO is delisted the Secretary will promptly publish in the Federal Register and on the AHRQ PSO website, or in a comparable future form of public notice, a notice of the actions taken and the effective dates.

A PSO can notify AHRQ of its intention to voluntarily relinquish its status as a PSO at any time. The requirements for seeking voluntary relinquishment can be found at section 3.108(c) of the Patient Safety Rule. In particular, please review sections 3.108(c)(2)(i) and (c)(2)(ii) of the Patient Safety Rule concerning the requirements for the disposition of patient safety work product (PSWP) at delisting.

In order to request voluntary relinquishment, please submit this form to AHRQ's PSO Office via email, at pso@ahrq.hhs.gov. To submit a hard copy, please send to: PSO Office, AHRQ, 5600 Fishers Lane, MS 06N100B, Rockville, MD 20857. This form must be signed by the Authorized Official.

PART I: PSO INFORMATION

PSO Name

PSO Number

PART II: REQUEST FOR VOLUNTARY RELINQUISHMENT

The PSO hereby provides notice that it wishes to relinquish its listing on the following date [mm/dd/yyyy] Note: If the proposed voluntary relinquishment is accepted, the Secretary's response will indicate the effective date and time for the entity's removal from the list of PSOs and will provide public notice of the voluntary relinquishment and the effective date and time of the delisting, in accordance with section 3.108(d) of the Patient Safety Rule.
Following delisting, any future communication should be sent to (this information will be included on the AHRQ PSO web site)
Contact Name
Street Address	City	State	Zip Code
Phone

PART III: ATTESTATIONS REGARDING DISPOSITION REQUIREMENTS

1.

Does the PSO have PSWP?

If answer is yes, proceed to questions 2 and 3, and then sign form.

If answer is no, skip questions 2 and 3, and then sign form.

___ Yes

___ No

2.

Do you attest that all reasonable efforts have been made, or will have been made by the PSO within 15 calendar days of this statement, to notify the sources (including other PSOs) from which the PSO received PSWP of the PSO’s intention to: 1) cease PSO operations and activities; 2) relinquish voluntarily its status as a PSO; 3) request that these other entities cease reporting or submitting any further information to the PSO as soon as possible; and 4) inform the sources that any information reported after the effective date and time of delisting that the Secretary sets will not be protected as PSWP under the Patient Safety Act?

___ Yes

___ No

3.

Do you attest that the entity has established a plan, or within 15 calendar days of this statement, will have made all reasonable efforts to establish a plan, in consultation with the sources from which it received PSWP, that provides for the disposition of the PSWP held by the PSO that is consistent with, to the extent practicable, the statutory options for disposition of PSWP as set out in section 3.108 (b)(3) of the Patient Safety Rule? The options are:

(i) Transfer such PSWP or data, with the approval of the source from which it was received, to a PSO that has agreed to receive such patient safety work product or data;

(ii) Return such work product or data to the source from which it was submitted; or

(iii) If returning such PSWP or data to its source is not practicable, destroy such PSWP or data.

NOTE: If the PSWP or data contains protected health information, the PSO must ensure that it meets the Patient Safety Rule disposition requirements as well as the terms of its business associate agreements and all applicable HIPAA requirements.

___ Yes

___ No

PART IV: CERTIFICATION OF ATTESTATIONS

I am legally authorized to complete this form on behalf of the entity seeking voluntary relinquishment as a PSO. The statements on this form are made in good faith and are true, complete, and correct to the best of my knowledge and belief. I understand that a knowing and willful false statement on this form can be punished by fine or imprisonment or both (United States Code, Title 18, Section 1001).

Authorized Official Information

Printed Name  

Title

Organization (if different from PSO)

 Phone

Email

***This form must be signed and dated by the authorized official on record with AHRQ.***

Signature

 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, 5600 Fishers Lane, MS 06N100B, Rockville, MD 20857.