Criminal Conviction (Guilty Plea or Trial)

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

OMB: 0915-0126

IC ID: 206488

Documents and Forms
Information Collection (IC) Details

View Information Collection (IC)

Criminal Conviction (Guilty Plea or Trial)
 
No Modified
 
Mandatory
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction 9 Criminal Conviction (Guilty Plea or Trial) 9 CriminalConvictionIndivAndOrgReport.pdf Yes Yes Fillable Fileable

Health Consumer Health and Safety

 

2,245 0
   
State, Local, and Tribal Governments
 
   100 %

  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 2,245 0 1,222 0 0 1,023
Annual IC Time Burden (Hours) 981 0 214 0 0 767
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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