Certification for Initial Listing Form

The Patient Safety and Quality Improvement Act of 2005 (Patient Safety Act) authorizes the creation 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 the PSO website at pso.ahrq.gov.

This form sets forth the requirements that all entities seeking listing as a PSO must certify they meet to become a PSO. Please review the Patient Safety Act, Patient Safety Rule, and all HHS Guidance before making the required attestations below. All references to "section" followed by a citation that begins with the number 3 within this form (e.g., "section 3.102") refer to sections of the Patient Safety Rule (73 F.R. 70732), which is codified in Title 42, Part 3 of the CFR. All references to Secretary within this form refers to the Secretary of Health and Human Services.