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 PSO Certification for Initial Listing Form
Attachment D_PSO Certification for Continued Listing Form Modified 40 320 0 Form and Instruction Form 2 PSO Certification for Continued Listing Form
Attachment E_PSO Two Bona Fide Contracts Requirement Form Modified 56 56 0 Form and Instruction Form 3 PSO Two Bona Fide Contracts Requirement Form
Attachment F_PSO Disclosure Statement Form Modified 3 9 0 Form and Instruction Form 4 PSO Disclosure Statement
Attachment G_PSO Profile Form Modified 74 222 0 Form and Instruction Form 5 PSO Profile Form
Attachment H_PSO Change of Listing Information Modified 51 4 0 Form and Instruction Form 6 PSO Change of Listing Information
Attachment I_OCR Complaint Consent Form New 1 0 0 Form and Instruction 8 OCR Complaint Consent Form
Attachment J_PSO Voluntary Relinquishment Form Modified 4 2 0 Form and Instruction Form 7 PSO Request for Voluntary Relinquishment
Attachment K: OCR Patient Safety Confidentiality Complaint Form Removed 0 0 0 Form and Instruction Form #7 Attachment I: OCR Patient Safety Confidentiality Complaint Form
Attachment K_AHRQ Common Formats Modified 1000 100000 0 Form and Instruction Form 9 AHRQ Common Formats
Total burden requested under this ICR: 1240 100811 0  
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