Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Attachment C_Patient Safety Organization Certification for Initial Listing Form Modified 11 198 0 Form and Instruction Form 1
Attachment D_PSO Certification for Continued Listing Form Modified 40 320 0 Form and Instruction Form 2
Attachment E_PSO Two Bona Fide Contracts Requirement Form Modified 56 56 0 Form and Instruction Form 3
Attachment F_PSO Disclosure Statement Form Modified 3 9 0 Form and Instruction Form 4
Attachment G_PSO Profile Form Modified 74 222 0 Form and Instruction Form 5
Attachment H_PSO Change of Listing Information Modified 51 4 0 Form and Instruction Form 6
Attachment I_OCR Complaint Consent Form New 1 0 0 Form and Instruction 8
Attachment J_PSO Voluntary Relinquishment Form Modified 4 2 0 Form and Instruction Form 7
Attachment K: OCR Patient Safety Confidentiality Complaint Form Removed 0 0 0 Form and Instruction Form #7
Attachment K_AHRQ Common Formats Modified 1000 100000 0 Form and Instruction Form 9
Total burden requested under this ICR: 1240 100811 0  
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