-
pso.ahrq.gov/image-captcha-refresh/user_login_form
{"status":1,"message":"","data":{"url":"\/image-captcha-generate\/10593\/1633360712","token":"mGkDXf655aZh2olfhiZLqm3erakHN8vTsMCOrw2EyuM","sid":"10593"}}
-
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
-
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. … ALTERNATE VERSION
Download a blank PDF version of this form. … https://pso.ahrq.gov/forms/initial-listing
Back to Top
-
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
-
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.
-
pso.ahrq.gov/sites/default/files/wysiwyg/PSO_BonaFideContracts.pdf
January 21, 2021 - 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.
-
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
-
pso.ahrq.gov/sites/default/files/wysiwyg/PSO_Voluntary_Relinquishment.pdf
January 03, 2022 - 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.
-
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.
-
pso.ahrq.gov/sites/default/files/wysiwyg/PSO_Disclosure.pdf
October 12, 2022 - 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:
-
pso.ahrq.gov/sites/default/files/wysiwyg/Role%20of%20AO_July%202016_FINAL.pdf
July 01, 2016 - 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.
-
pso.ahrq.gov/sites/default/files/wysiwyg/what-is-the-role-of-ao-june-2017.pdf
January 01, 2017 - 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.
-
pso.ahrq.gov/sites/default/files/wysiwyg/PSO_ChangeOfListingInfo.pdf
December 17, 2021 - 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
-
pso.ahrq.gov/sites/default/files/wysiwyg/PSO_ContinuedListing.pdf
February 15, 2022 - 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.
-
pso.ahrq.gov/sites/default/files/wysiwyg/PSO_InitialListing.pdf
February 15, 2022 - 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.
-
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
-
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
-
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
-
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
-
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