OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

Health Integrity and Protection Data Bank for Final Adverse Information on Health Care Providers, Suppliers and Practitioners

IC 6485 under ICR 201010-0915-005 · OMB 0915-0239.

Documents and Forms

Documents and forms in this information collection
Document NameDocument Type
Form hipdb_001
Health Integrity and Protection Data Bank for Final Adverse Information on Health Care Providers, Suppliers and Practitioners		 Form and Instruction
NPDB-HIPDB Subscriber Agreement-NonPayingUsers_1-0h_20100607b_002.doc Instruction
NPDB-HIPDB Subscriber Agreement-SelfQuery_1-0d_20100611b.doc Instruction
hipdb_001 hipdb_001
NPDB-HIPDB_1_Updated.pdf 		Form and Instruction
hipdb_002 hipdb_002
NPDB-HIPDB_2_Updated.pdf 		Form and Instruction
hipdb_eauth_001 hipdb_eauth_001
NPDBRegCertOfficial-DBAdmin_v1-0b_20100607_001.doc 		Form and Instruction
hipdb_eauth_003 hipdb_eauth_003
NPDBRegAdminv_1-0g_20100607.doc 		Form and Instruction
hipdb_eauth_002 hipdb_eauth_002
NPDBRegCertOfficial_v1-0g_20100607.doc 		Form and Instruction
hipdb_eauth_004 hipdb_eauth_004
NPDBRegInvestigativeSearch_1-0g_20100611.doc 		Form and Instruction
hipdb_eauth_005 hipdb_eauth_005
NPDBRegSelf-Query_v1-0a_20100524.doc 		Form and Instruction
hipdb_eauth_006 hipdb_eauth_006
NPDBRegUser_v1-0g_20100611.doc 		Form and Instruction
hipdb_eauth_007 hipdb_eauth_007
NPDBRegUserNotary_v1-0d_20100611.doc 		Form and Instruction
hipdb_eauth_008 hipdb_eauth_008
NPDBRevokeAccount_1-0b_20100514ks.doc 		Form and Instruction
NPDB_RPS_003_policy statement.doc
Registration Practices Statement		IC Document

Information Collection (IC) Details

View Information Collection (IC)

layout table

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 hipdb_001 hipdb_001 NPDB-HIPDB_1_Updated.pdf Yes Yes Fillable Fileable
Form and Instruction hipdb_002 hipdb_002 NPDB-HIPDB_2_Updated.pdf Yes Yes Fillable Fileable
Form and Instruction hipdb_eauth_001 hipdb_eauth_001 NPDBRegCertOfficial-DBAdmin_v1-0b_20100607_001.doc Yes Yes Fillable Fileable
Instruction NPDB-HIPDB Subscriber Agreement-NonPayingUsers_1-0h_20100607b_002.doc Yes No Printable Only
Instruction NPDB-HIPDB Subscriber Agreement-SelfQuery_1-0d_20100611b.doc Yes No Printable Only
Form and Instruction hipdb_eauth_003 hipdb_eauth_003 NPDBRegAdminv_1-0g_20100607.doc Yes Yes Fillable Fileable
Form and Instruction hipdb_eauth_002 hipdb_eauth_002 NPDBRegCertOfficial_v1-0g_20100607.doc Yes Yes Fillable Fileable
Form and Instruction hipdb_eauth_004 hipdb_eauth_004 NPDBRegInvestigativeSearch_1-0g_20100611.doc Yes Yes Fillable Fileable
Form and Instruction hipdb_eauth_005 hipdb_eauth_005 NPDBRegSelf-Query_v1-0a_20100524.doc Yes Yes Fillable Fileable
Form and Instruction hipdb_eauth_006 hipdb_eauth_006 NPDBRegUser_v1-0g_20100611.doc Yes Yes Fillable Fileable
Form and Instruction hipdb_eauth_007 hipdb_eauth_007 NPDBRegUserNotary_v1-0d_20100611.doc Yes Yes Fillable Fileable
Form and Instruction hipdb_eauth_008 hipdb_eauth_008 NPDBRevokeAccount_1-0b_20100514ks.doc Yes Yes Fillable Fileable

Federal Enterprise Architecture Business Reference Module


table that charts list of burden
  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 985,754 0 0 0 0 985,754
Annual IC Time Burden (Hours) 146,190 0 25,208 0 0 120,982
Annual IC Cost Burden (Dollars) 4,980,736 0 1,115,458 0 0 3,865,278

Documents for IC
table that charts IC Documents
Title Document Date Uploaded
Registration Practices Statement NPDB_RPS_003_policy statement.doc 10/20/2010
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.