Disclosure Form - Revised

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

OMB: 0935-0143

IC ID: 186801

Information Collection (IC) Details

View Information Collection (IC)

Disclosure Form - Revised
 
No Modified
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction Form #4 Attachment F: PSO Disclosure Statement Form FINAL_PSO disclosure_edits_06-10-2021.docx https://www.pso.ahrq.gov/forms/disclosure Yes Yes Fillable Fileable

Health Consumer Health and Safety

 

2 0
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   100 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 2 0 -1 0 0 3
Annual IC Time Burden (Hours) 6 0 -3 0 0 9
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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