Attachment F_PSO Disclosure Statement Form

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

Documents and Forms

Document Name Document Type
Form Form 4 Attachment F_PSO Disclosure Statement Form Form and Instruction
Form 4 PSO Disclosure Statement Attachment F_DRAFT_PSO Disclosure Statement Form.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Attachment F_PSO Disclosure Statement Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	Form 4	PSO Disclosure Statement	Attachment F_DRAFT_PSO Disclosure Statement Form.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 3	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Program Change Due to Agency Discretion	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	3	1	2
Annual IC Time Burden (Hours)	9	3	6
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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