Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Disclosure Form Removed 0 0 0 Form and Instruction Form #3 Disclosure Form
Disclosure Form - Revised New 17 9 0 Form and Instruction Form #3 Disclosure Form 10/2/2008
Information Form Removed 0 0 0 Form and Instruction Form #5 Information Form
Information Form - Revised New 33 17 0 Form and Instruction Form #5 Information Form 10/2/2008
Patient Safety Confidentiality Complaint Form Removed 0 0 0 Form and Instruction Form #6 Patient Safety Confidentiality Complaint Form
Patient Safety Confidentiality Complaint Form - Revised New 50 17 0 Form and Instruction Form #6 Patient Safety Confidentiality Complaint Form 10/2/2008
Patient Safety Organization Certification Form Removed 0 0 0 Form and Instruction Form #1 Patient Safety Organization Certification Form
Patient Safety Organization Certification Form - Revised New 33 17 0 Form and Instruction Form #1 Patient Safety Organization Certification Form 10/2/2008
Recertification Form Removed 0 0 0 Form and Instruction Form #2 Recertification Form
Recertification Form - Revised New 17 9 0 Form and Instruction Form #2 Recertification Form 10/2/2008
Two-Contract Requirement Form Removed 0 0 0 Form and Instruction Form #4 Two-Contract Requirement Form
Two-Contract Requirement Form - Revised New 33 8 0 Form and Instruction Form #4 Two-Contract Requirement Form 10/2/2008
Total burden requested under this ICR: 183 77 0  
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