Certification for Continued Listing Form

Patient Safety Organization Certification for Initial Listing and Related Forms, Patient Safety Confidentiality Complaint Form, and Common Formats

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0935-0143 can be found here:

Documents and Forms

Document Name Document Type
Form Form #2 Certification for Continued Listing Form Form and Instruction
Form #2 Attachment D: PSO Certification for Continued Listing Fo FINAL_PSO cert of continued listing__AHRQ_edits_06-10-2021.docx www.pso.ahrq.gov/forms/continued Form and Instruction
Form #2 Attachment D: PSO Certification for Continued Listing Fo FINAL_PSO cert of continued listing__AHRQ_edits_06-10-2021.docx www.pso.ahrq.gov/forms/continued Form and Instruction

Information Collection (IC) Details

IC Title:	Certification for Continued Listing Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	Form #2	Attachment D: PSO Certification for Continued Listing Form	FINAL_PSO cert of continued listing__AHRQ_edits_06-10-2021.docx	https://www.pso.ahrq.gov/forms/continued	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 42	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	42	21	21
Annual IC Time Burden (Hours)	336	168	168
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.