Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Attachment J: PSO Change of Listing Information Modified 61 5 0 Form and Instruction Form 6
Attachment K: OCR Patient Safety Confidentiality Complaint Form Modified 1 0 0 Form and Instruction Form #7
Attachment L: PSO Voluntary Relinquishment Form New 5 3 0 Form and Instruction 8
Certification for Continued Listing Form Modified 21 168 0 Form and Instruction Form #2
Common Formats Modified 1000 100000 0 Form and Instruction Form #9
Disclosure Form - Revised Modified 3 9 0 Form and Instruction Form #4
Information Form - Revised Modified 70 210 0 Form and Instruction Form #5
Patient Safety Organization Certification for Initial Listing Form Modified 16 288 0 Form and Instruction Form #1
Two Bona Fide Contracts Requirement Form Modified 42 42 0 Form and Instruction Form #3
Total burden requested under this ICR: 1219 100725 0  
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