Attachment L: PSO Voluntary Relinquishment 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⚠️ Notice: This information collection may be referencing outdated material.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 8 Attachment L: PSO Voluntary Relinquishment Form Form and Instruction
8 Attachment J: PSO Voluntary Relinquishment Form FINAL_PSO Voluntary relinquishment_edits_06-10-2021.docx Form and Instruction
8 Attachment J: PSO Voluntary Relinquishment Form FINAL_PSO Voluntary relinquishment_edits_06-10-2021.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Attachment L: PSO Voluntary Relinquishment 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	8	Attachment J: PSO Voluntary Relinquishment Form	FINAL_PSO Voluntary relinquishment_edits_06-10-2021.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 4	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	4	-1	5
Annual IC Time Burden (Hours)	2	-1	3
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.