Section 1921 forms

National Practitioner Data Bank for Adverse Information on Physicians and Other Health Care Practitioners: Regulations and Forms

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Document Name Document Type
Form 2 Section 1921 forms Form and Instruction
2 60.10: Adverse Actions - Private Accreditation Accreditation Initial - Organization Subject.pdf Form and Instruction
1 60.9: Licensure Actions State Licensure Initial - Individual Subject.pdf Form and Instruction
3 60.10: Adverse Actions - Peer Review Organizations Peer Review Organization Initial - Individual Subject.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Section 1921 forms	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	2	60.10: Adverse Actions - Private Accreditation	Accreditation Initial - Organization Subject.pdf	Yes	Yes	Fillable Fileable Signable
Form and Instruction	1	60.9: Licensure Actions	State Licensure Initial - Individual Subject.pdf	Yes	Yes	Fillable Fileable Signable
Form and Instruction	3	60.10: Adverse Actions - Peer Review Organizations	Peer Review Organization Initial - Individual Subject.pdf	Yes	Yes	Fillable Fileable Signable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 39	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	61	61
Annual IC Time Burden (Hours)	46	46
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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