Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Attachment J: PSO Change of Listing Information Modified 54 5 0 Form and Instruction Form 6 Attachment H: PSO Change of Listing Information
Attachment K: OCR Patient Safety Confidentiality Complaint Form Modified 1 0 0 Form and Instruction Form #7 Attachment I: OCR Patient Safety Confidentiality Complaint Form
Attachment L: PSO Voluntary Relinquishment Form Modified 4 2 0 Form and Instruction 8 Attachment J: PSO Voluntary Relinquishment Form
Certification for Continued Listing Form Modified 42 336 0 Form and Instruction Form #2 Attachment D: PSO Certification for Continued Listing Form
Common Formats Modified 1000 100000 0 Form and Instruction Form #9 Attachment K: Common Formats Details
Disclosure Form - Revised Modified 2 6 0 Form and Instruction Form #4 Attachment F: PSO Disclosure Statement Form
Information Form - Revised Modified 72 216 0 Form and Instruction Form #5 Attachment G: PSO Profile Form
Patient Safety Organization Certification for Initial Listing Form Modified 10 180 0 Form and Instruction Form #1 Attachment C: PSO Certification for Initial Listing Form
Two Bona Fide Contracts Requirement Form Modified 51 51 0 Form and Instruction Form #3 Attachment E: PSO Two Bona Fide Contracts Requirement Form
Total burden requested under this ICR: 1236 100796 0  
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