Forms

Any entity seeking listing as a Patient Safety Organization (PSO) is encouraged to contact the PSO Program prior to submitting the Certification of Initial Listing form. Forms can also be submitted as hard copies to the PSO Program. AHRQ will acknowledge submissions within two business days. For questions about form submission, please contact the PSO Program.

Certification for Initial Listing Form

AHRQ has prepared a PSO Certification for Initial Listing form for any entity that wants to become a listed PSO. Prior to completing and submitting this form, AHRQ encourages entities to contact the PSO Program. Applications can be submitted at any time.

Two Bona Fide Contracts Form

To remain listed, each PSO is required to have two bona fide contracts for the conduct of patient safety activities with different health care providers. This form must be submitted within 24 months of the PSO’s initial listing date and each succeeding 24-month period.

The PSO listing will show certain important facts:

  • A PSO's initial date of listing
  • The period that the two bona fide contracts requirement must be met (including the date that the PSO fulfilled the requirement), and
  • Whether AHRQ has been notified that the PSO has met the requirement in the current 24-month period of listing.

PSOs are encouraged to refer to the following sections of the Patient Safety Rule for more information on the Bona Fide Contracts Requirement:

Disclosure Statement Form

Every time a PSO enters a Patient Safety Act contract, the PSO will need to determine whether it needs to submit a Disclosure Statement. AHRQ recommends contacting the PSO Program to determine how and if this form is necessary.

Continued Listing Form

A listing with AHRQ automatically expires after 3 years if it is not renewed. PSOs must submit Certification for Continued Listing no later than 75 days before the expiration of the 3-year period. Before submitting the form, AHRQ will contact the PSO to schedule at least two calls to review the PSO’s progress in meeting those requirements. These discussions will begin approximately six months before the listing expires.

See Sections 3.102(b)(1)(ii) of the rule for more information.

PSO Change of Listing Information Form

This an administrative form which is used by a PSO to revise information for its officials and organizations, and to update the contact information for their PSO, including changes to addresses, telephone numbers, and Web sites. As required in the Patient Safety Rule, section 3.102(a)(vi), a PSO must promptly notify the Secretary during its period of listing if there have been any changes in the accuracy of the information submitted for listing, along with those changes.

PSO Profile

The PSO Profile gathers information on the type of healthcare providers and settings that PSOs are working with to conduct patient safety activities in order to improve patient safety. For example, data reflecting the 2016 reporting period (i.e. the 2016 calendar year) should be submitted no later than February 28, 2016. PSOs should update their PSO Profile online by February 28th of each year. The information should be entered electronically at the PSO Privacy Protection Center Web site. Please contact support@psoppc.org for further information.

Patient Safety Complaint Form

The Department of Health and Human Services' Office for Civil Rights (OCR) is responsible for the implementation and enforcement of the confidentiality provisions of the Patient Safety Act and Patient Safety Rule. Confidentiality provisions permit patient safety work product (PSWP) to be disclosed only in accordance with specific disclosure permissions (see 42 CFR 3.206). A complaint can be filed against a person or organization that impermissibly disclosed PSWP, and OCR provides information on how to file a complaint.