Disclosure Statement Form

The Patient Safety and Quality Improvement Act of 2005 (Patient Safety Act), and its implementing regulations at 42 CFR Part 3 (Patient Safety Rule), establish a system of Patient Safety Organizations (PSOs). The Agency for Healthcare Research and Quality (AHRQ) of the Department of Health and Human Services (HHS) administers the provisions of the Patient Safety Act and Patient Safety Rule dealing with PSO operations. Information related to PSOs is available on AHRQ's PSO Web site at pso.ahrq.gov.

Select to download a blank form in PDF format.

PDF of the completed form will be sent to the Authorized Official email address provided above.

This completed form is considered public information.

Burden Statement

Public reporting burden for the collection of information is estimated to average 3 hours per response. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: AHRQ Reports Clearance Officer, Attention: PRA, Paperwork Reduction Project (0935-0143), AHRQ, 5600 Fishers Lane, Rockville, MD 20857.

Form Approved

OMB No. 0935-0143

Exp. Date 12/31/2017

Are you ready to submit the completed form to the AHRQ PSO Program?