Information Collection

National Practitioner Data Bank for Adverse Information on Physicians and Other Health Care Pract

IC 6361 under ICR 201009-0915-005 · OMB 0915-0126.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0126 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form NPDB Identity Proo National Practitioner Data Bank for Adverse Information on Physicians and Other Health Care Pract	Form and Instruction
NPDB Identity Proo NPDB Identity Proofing Forms NPDB-HIPDB E-Authentication and Identity Proofing Forms.doc	Form and Instruction
0915-0126 NPDB For NPDB Forms 0915-0126_NPDB Forms_2010.pdf	Form
0915-0126_Form Changes From 2007 to 2010_Revision.9.1.10.doc Form Changes from 2007-2010	IC Document

IC Title:

National Practitioner Data Bank for Adverse Information on Physicians and Other Health Care Pract

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 45 CFR 60

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	NPDB Identity Proofing Forms	NPDB Identity Proofing Forms	NPDB-HIPDB E-Authentication and Identity Proofing Forms.doc		Yes	Yes	Fillable Fileable
Form	0915-0126 NPDB Forms	NPDB Forms	0915-0126_NPDB Forms_2010.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: National Practitioner Data Bank for Adverse Information on Physicians and Other Health Care Practitioners, HHS/HRSA/BHPr

FR Citation: 62 FR 12653

Number of Respondents: 32,389

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	3,720,431	0	-1,771	3,722,202
Annual IC Time Burden (Hours)	324,777	1,083	0	323,694
Annual IC Cost Burden (Dollars)	16,732,083	0	-7,965	16,740,048

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Form Changes from 2007-2010	0915-0126_Form Changes From 2007 to 2010_Revision.9.1.10.doc	09/07/2010

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.