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1. Forms | PSO
   pso.ahrq.gov/forms
   February 01, 2022 - SHARE: More topics in this section Forms … Forms Initial Listing Certification Forms Patient Safety Organizations … (PSOs) are encouraged to complete and submit forms online. … Forms can also be downloaded for completion and emailed or mailed. … https://pso.ahrq.gov/forms   Back to Top

2. Certification for Initial Listing Form | PSO
   pso.ahrq.gov/forms/initial-listing
   February 01, 2022 - topics in this section My PSO Account Certification for Initial Listing Form … Instructions for Completing the Form The Patient Safety and Quality Improvement Act of 2005 … All references to Secretary within this form refers to the Secretary of Health and Human Services. … Next ALTERNATE VERSION Download a blank PDF version of this form. … https://pso.ahrq.gov/forms/initial-listing   Back to Top

3. Prepare to Submit the Certification for Initial Listing Form | PSO
   pso.ahrq.gov/become/submit-certification
   August 01, 2021 - Prospective PSO Authorized Official (AO) Prepare to Submit the Certification for Initial Listing Form … The Certification for Initial Listing Form requires the name, address, and other administrative … The applicant must also disclose in the Certification for Initial Listing Form if the entity (under its … on behalf of the entity seeking listing as a PSO and must certify that the "…statements on this form … I understand that a knowing and willful false statement on this form, attachments or supplements to it

4. Sample Filing Timeline | PSO
   pso.ahrq.gov/maintain/sample-timeline
   June 01, 2022 - As needed: Describes the submission timeline for forms that become required only if and when certain … Please contact AHRQ for the status of any forms you may have submitted in this category. … PSO Profile Forms were not collected prior to 2012.   … PSO Profile Forms were not collected prior to 2012.   … PSO Profile Forms were not collected prior to 2012.  

5. Patient Safety Organization: Two Bona Fide Contracts Requirement (pdf file)
   pso.ahrq.gov/sites/default/files/wysiwyg/PSO_BonaFideContracts.pdf
   September 30, 2024 - Form … All references to Secretary within this form refer to the Secretary of HHS. … Do not submit copies of the contracts with this form unless requested by AHRQ. … Please submit this form to AHRQ’s PSO Office via email, at pso@ahrq.hhs.gov. … This form must be signed by the Authorized Official.

6. Patient Safety Organization: Request For Voluntary Relinquishment (pdf file)
   pso.ahrq.gov/sites/default/files/wysiwyg/PSO_Voluntary_Relinquishment.pdf
   September 30, 2024 - For Voluntary Relinquishment Form … All references to Secretary within this form refer to the Secretary of HHS. … This form must be signed by the Authorized Official. … If answer is “Yes”, proceed to questions 2 and 3, and then sign form. … If answer is “No”, skip questions 2 and 3, and then sign form. Yes No 2.

7. How To Maintain a PSO Listing | PSO
   pso.ahrq.gov/maintain
   June 01, 2022 - The forms containing the certifications needed to maintain a PSO listing are available for online submission … Once a PSO is listed, online forms pre-populate with the PSO's administrative information. … PSO Authorized Officials can access online forms for their PSO by logging in to their My PSO Account … If necessary, forms can be downloaded from AHRQ's PSO website, completed, and submitted by email or regular … Work With a PSO Become a PSO Maintain a PSO Listing PSOs Common Formats Forms

8. Patient Safety Organization: Disclosure Statement (pdf file)
   pso.ahrq.gov/sites/default/files/wysiwyg/PSO_Disclosure.pdf
   September 30, 2024 - Disclosure Statement Form … All references to Secretary within this form refer to the Secretary of HHS. … This form must be signed by the PSO’s Authorized Official. … Please submit completed forms to AHRQ’s PSO Office via e-mail, at pso@ahrq.hhs.gov. … : If “Yes,” in lieu of completing this form: Date: Revised Date:

9. What Is the Role of the PSO Authorized Official? (pdf file)
   pso.ahrq.gov/sites/default/files/wysiwyg/what-is-the-role-of-ao.pdf
   July 01, 2021 - A PSO’s failure to timely submit these forms could result in the PSO’s delisting. … These forms, all available at the AHRQ PSO website (https://pso.ahrq.gov/forms), include: Two Bona Fide … Contracts Requirement Form, Disclosure Statement Form, Certification for Continued Listing Form, and … Change of Listing Information Form. … All of these forms must be signed by the PSO’s AO.

10. Patient Safety Organization: Change of Listing Information (pdf file)
    pso.ahrq.gov/sites/default/files/wysiwyg/PSO_ChangeOfListingInfo.pdf
    September 30, 2024 - Patient Safety Organization: Change of Listing Information Form Approved OMB … change(s) in listing information that are the subject of this notification; and, have the completed form … Please submit this form to AHRQ’s PSO Office via e-mail, at pso@ahrq.hhs.gov. … Email Phone Extension (if applicable) Reason for change(s) Page 2 of 3 ***This form … dated by the Authorized Official on record with AHRQ.*** Name Signature Date This completed form

11. PSO: Certification of Continued Listing (pdf file)
    pso.ahrq.gov/sites/default/files/wysiwyg/PSO_ContinuedListing.pdf
    September 30, 2024 - PSO: Certification of Continued Listing Form Approved OMB Control No: 0935-0143 Exp. date: 09/30 … This form sets forth the requirements that all PSOs seeking continued listing must certify they meet … All references to Secretary within this form refer to the Secretary of HHS. … A PSO seeking continued listing must complete this form and submit it to AHRQ’s PSO Office via email, … This completed form is considered public information.

12. Patient Safety Organization: Certification for Initial Listing (pdf file)
    pso.ahrq.gov/sites/default/files/wysiwyg/PSO_InitialListing.pdf
    September 30, 2024 - Listing Form … This form sets forth the requirements that all entities seeking listing as a PSO must certify they meet … All references to Secretary within this form refer to the Secretary of HHS. … Entities seeking listing are encouraged to contact AHRQ’s PSO Office before submitting this form. … Date This completed form is considered public information.

13. Become a Patient Safety Organization | PSO
    pso.ahrq.gov/become
    March 01, 2022 - Prospective PSO Authorized Official (AO) Prepare to Submit the Certification for Initial Listing Form … Prospective PSO Authorized Official ("AO") Prepare to Submit the Certification for Initial Listing Form … Related Links PSO Listing Guide (PDF, 716 KB) Complete the Initial Listing Form PSO Program: Common

14. Assess Compatibility of Anticipated PSO Operations with Patient Safety Rule Requirements | PSO
    pso.ahrq.gov/become/assess-compatibility
    August 01, 2021 - Prospective PSO Authorized Official (AO) Prepare to Submit the Certification for Initial Listing Form … Patient Safety Rule Requirements The individual who signs the Certification for Initial Listing Form … PSO's operations and services in relation to each requirement in the Certification for Initial Listing Form … co-located with non-patient safety work product, to make it distinguishable so that the appropriate form … Prospective PSO Authorized Official ("AO") Prepare to Submit the Certification for Initial Listing Form

15. Assess Eligibility to Become a PSO | PSO
    pso.ahrq.gov/become/assess-eligibility
    August 01, 2021 - Prospective PSO Authorized Official (AO) Prepare to Submit the Certification for Initial Listing Form … The following types of "excluded entities" cannot themselves become a PSO, but they may be able to form … One consideration in deciding whether to form a component organization to apply for PSO listing is that … Prospective PSO Authorized Official ("AO") Prepare to Submit the Certification for Initial Listing Form

16. Establish Policies and Procedures for Conducting Patient Safety Activities | PSO
    pso.ahrq.gov/become/establish-policies
    August 01, 2021 - Prospective PSO Authorized Official (AO) Prepare to Submit the Certification for Initial Listing Form … Patient Safety Activities Before completing and submitting the Certification for Initial Listing Form … Prospective PSO Authorized Official ("AO") Prepare to Submit the Certification for Initial Listing Form

17. PSO Quiz--Answer Sheet (pdf file)
    pso.ahrq.gov/sites/default/files/quiz/pso-quiz-answer-sheet.pdf
    January 01, 2020 - True [The PSO Change of Listing Information form can be used to notify AHRQ of a change in contact … The PSO may wish to contact AHRQ before using this form if there are changes that may affect the PSO … Information assembled or developed to meet an external obligation cannot, in its original form, become … True [The nurse’s written statement cannot become PSWP in its original form under either pathway of

18. Patient Safety Organization (PSO) Listing Guide (pdf file)
    pso.ahrq.gov/sites/default/files/wysiwyg/PSO-listing-guide-2022.pdf
    January 01, 2022 - The AO must have full authority to sign the certification for listing forms containing Page 18 … Once a PSO is listed, online forms pre-populate with the PSO’s administrative information. … PSO Authorized Oficials can access online forms for their PSO by logging in to their ‘My PSO Account … If necessary, forms can be downloaded from AHRQ’s PSO website, completed, and submitted by email or … The Change of Listing Information Form is an administrative form that can be used by the PSO’s Authorized

19. Select the Prospective PSO Authorized Official (AO) | PSO
    pso.ahrq.gov/become/select-authorized-official
    August 01, 2021 - Prospective PSO Authorized Official (AO) Prepare to Submit the Certification for Initial Listing Form … The AO must have full authority to sign the certification for listing forms containing the attestations … for Conducting Patient Safety Activities Prepare to Submit the Certification for Initial Listing Form

20. PSO Common Terms and Acronyms | PSO
    pso.ahrq.gov/resources/acronyms
    August 01, 2021 - (HERF); it is one of 3 general forms of AHRQ’s Common Formats. … This form is not available in versions after Hospital version 1.2. … PIF – Patient Information Form (PIF); it is one of 3 general forms of AHRQ's Common Formats. … This form is not available in versions after Hospital version 1.2. … SIR – Summary of Initial Report (SIR) Form; it is one of 3 general forms of AHRQ's Common Formats.