Instructions to Obtain and Submit the Contact Information Form
**Newly licensed Pennsylvania facilities or facilities that have not reported through the Pennsylvania Patient Safety Reporting System (PA-PSRS) to date can contact PA-PSRS support for more information.**
For existing reporting facilities to submit a contact form to the Pennsylvania Patient Safety Authority, a PA-PSRS user with a current user ID and password is required to log on to PA-PSRS. Upon log-on, scroll over the “Resources” tab in the top navigation. Then, click on “Facility Contact Form” to access and/or download the form for one-time use. The form can then be completed and submitted to PA-PSRS support staff. The fax number and e-mail address are located at the bottom of the form. If you prefer to e-mail the form, you would first need to save the PDF form to your desktop, complete the form, open your e-mail client, and attach the PDF form to the e-mail. You must have Adobe Reader to fill in the form fields of the PDF. An Adobe Reader download is available below.
All Pennsylvania-licensed hospitals, ambulatory surgical facilities, abortion facilities, and birthing centers are subject to Act 13 of 2002 reporting requirements. All nursing homes and hospitals are subject to reporting requirements of healthcare-associated infections (HAIs) under Act 52 of 2007. The Pennsylvania Patient Safety Authority developed PA-PSRS to facilitate electronic reporting. If you are already registered to participate in PA-PSRS, you can log on to PA-PSRS.
To facilitate communications between all Pennsylvania-licensed hospitals, ambulatory surgical facilities, abortion facilities, birthing centers, nursing homes and the Authority, each facility should complete and return the aformentioned facility contact form designating the facility’s primary contact for information related to patient safety. This form can also be used to change or update contact information.
Adobe Portable Document Format (PDF)
Many documents on this site and on PA-PSRS are in Adobe Portable Document Format (PDF). Adobe Reader is freely available. You can download it here or through the icon below.