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Certification for Initial Listing Form

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Webform
  • 1 Current PART I: Entity Contact Information
  • 2 PART I: Entity Contact Information, continued
  • 3 PART II: Information and Attestations Regarding Organization and Structure
  • 4 PART III: Information and Attestations For Component Organizations
  • 5 PART III: Information and Attestations For Component Organizations, continued
  • 6 PART III: Information and Attestations For Component Organizations, continued
  • 7 PART IV: Attestations Regarding Patient Safety Activities and PSO Criteria
  • 8 PART IV: Attestations Regarding Patient Safety Activities and PSO Criteria, continued
  • 9 PART V: Certification of Attestations
PART I: Entity Contact Information
Please complete the following information about the entity seeking listing as a PSO, which, if the entity is listed, will be used for the "Listed PSOs" section of the AHRQ PSO website. If the entity seeking listing is a component of another (parent) organization, the name listed below cannot be identical to that of the parent organization. However, a component of the XYZ organization could seek listing as the XYZ PSO. To determine whether an entity is a component, consult the definitions of component and parent organizations in section 3.20.
Please enter a valid URL that starts with http:// or https://
Will the PSO have an alternate legal name?

Physical Address

Mailing Address

Phone Information

Please enter a valid 10-digit number, e.g., 5414566789. The system will add formatting, e.g., (541) 456-6789.
Page last reviewed February 2020
Page originally created February 2020

Internet Citation: Certification for Initial Listing Form. Content last reviewed February 2020. Agency for Healthcare Research and Quality, Rockville, MD.
https://pso.ahrq.gov/forms/initial-listing

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