Patient Safety Organization Certification for Initial Listing Form

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

OMB: 0935-0143

IC ID: 186804

Information Collection (IC) Details

View Information Collection (IC)

Patient Safety Organization Certification for Initial Listing Form
 
No Modified
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction Form #1 Attachment C: PSO Certification for Initial Listing Form FINAL_PSO cert of initial listing_Final edits_06-10-2021.docx www.pso.ahrq.gov Yes Yes Fillable Fileable

Health Consumer Health and Safety

 

10 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 10 0 -6 0 0 16
Annual IC Time Burden (Hours) 180 0 -108 0 0 288
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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