OMB
.report
Search
Attachment J_PSO Voluntary Relinquishment Form
Patient Safety Organization Certification for Initial Listing and Related Forms, Patient Safety Confidentiality Complaint Form, and Common Formats
OMB: 0935-0143
IC ID: 231738
OMB.report
HHS/AHRQ
OMB 0935-0143
ICR 202410-0935-002
IC 231738
( )
Documents and Forms
Document Name
Document Type
Form Form 7
Attachment J_PSO Voluntary Relinquishment Form
Form and Instruction
Form 7 PSO Request for Voluntary Relinquishment
Attachment J_DRAFT_PSO Voluntary Relinquishment.docx
Form and Instruction
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Attachment J_PSO Voluntary Relinquishment 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 7
PSO Request for Voluntary Relinquishment
Attachment J_DRAFT_PSO Voluntary Relinquishment.docx
Yes
Yes
Fillable Fileable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Health Care Services
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
4
Number of Respondents for Small Entity:
0
Affected Public:
Private Sector
Private Sector:
Not-for-profit institutions, Businesses or other for-profits
Percentage of Respondents Reporting Electronically:
100 %
Requested
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
4
0
0
0
4
0
Annual IC Time Burden (Hours)
2
0
0
0
2
0
Annual IC Cost Burden (Dollars)
0
0
0
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.