Information Collection List

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