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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. 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.  

4. 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.

5. 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

6. Fedregnotice-05242016 (pdf file)
   pso.ahrq.gov/sites/default/files/wysiwyg/fedregnotice-05242016.pdf
   January 04, 2025 - provider has no ongoing requirement to maintain the reported information, the subsequent collection of a form … in the PSES and reporting to a PSO would protect the later form as PSWP because the external obligation … The provider only maintains the forms outside of the PSES: The forms are not PSWP. … The provider only maintains the original forms in the PSES: The forms are original provider records … clear and discrete requirements would include requirements for a provider to fill out a particular form

7. Slide 1 (pdf file)
   pso.ahrq.gov/sites/default/files/wysiwyg/guidance-pswp-provider-obligations.pdf
   May 24, 2016 - The provider only maintains the forms outside of the PSES: The forms are not PSWP. 2. … : The original forms are not PSWP. 3. … The provider only maintains the original forms in the PSES: The forms are original provider records … The provider maintains the forms outside of the PSES and within the PSES extracts information from the … forms to conduct further analysis: The forms are not PSWP. 23 The Guidance: External Obligations

8. 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

9. 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

10. PSOs | PSO
    pso.ahrq.gov/pso
    June 01, 2025 - Work With a PSO Become a PSO Maintain a PSO Listing PSOs Common Formats Forms

11. 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:

12. 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.

13. 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.

14. 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.

15. PSO Program - Common Terms and Acronyms (pdf file)
    pso.ahrq.gov/sites/default/files/wysiwyg/pso-program-acronyms.pdf
    October 01, 2022 - HERF – Healthcare Event Reporting Form (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); 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.

16. 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.

17. 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

18. How To Choose a PSO | PSO
    pso.ahrq.gov/work-with/choose
    November 01, 2020 - AHRQ created the Common Formats (forms using common definitions and reporting formats) to facilitate

19. 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

20. 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.