Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Certification for Continued Listing Form Modified 24 192 0 Form and Instruction Form #2 PSO Certification for Continued Listing Form
Common Formats Modified 750 75000 0 Form and Instruction Form #7 Common Formats Complete Set of Forms
Disclosure Form - Revised Modified 7 21 0 Form and Instruction Form #4 PSO Disclosure Statement Form
Information Form - Revised Modified 80 240 0 Form and Instruction Form #5 PSO Information Form
Patient Safety Confidentiality Complaint Form Modified 3 1 0 Form and Instruction Form #6 Patient Safety Confidentiality Complaint Form
Patient Safety Organization Certification for Initial Listing Form Modified 15 270 0 Form and Instruction Form #1 Patient Safety Organization Certification for Initial Listing Form
Two Bona Fide Contracts Requirement Form Modified 40 40 0 Form and Instruction Form #3 PSO Two Bona Fide Contracts Requirement Form
Total burden requested under this ICR: 919 75764 0  
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