Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Attestation Form New 95 24 0 Form and Instruction Form #7 Attestation Form
Certification for Continued Listing Form Modified 17 9 0 Form and Instruction Form #6 Certification for Continued Listing Form
Disclosure Form - Revised Modified 17 9 0 Form and Instruction Form #5 Disclosure Statement Form
Information Form - Revised Modified 33 17 0 Form and Instruction Form #3 Information Form
Patient Safety Confidentiality Complaint Form Modified 50 17 0 Form and Instruction Form #1 Patient Safety Confidentiality Complaint Form
Patient Safety Organization Certification for Initial Listing Form Modified 33 17 0 Form and Instruction Form #4 Patient Safety Organization Certification for Initial Listing Form
Two Bona Fide Contracts Requirement Form Modified 33 8 0 Form and Instruction Form #2 Two Bona Fide Contracts Requirement Form
Total burden requested under this ICR: 278 101 0  
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