Form 33 LicensingBoardDataRequest

Data provided in 2013

Information for HHS/HRSA/Division of Practitioner Data Banks

Please provide information as indicated in the fields below & return by secure message to the Data Bank. Include disciplinary action data for the years xx/xx/xxxx through
xx/xx/xxxx, including actions taken in that timeframe to revise, modify, or reinstate any prior action. In addition, we are requesting those actions that a board may not
consider disciplinary but are reportable to the Data Bank (e.g., administrative suspensions, monetary penalties connected to the delivery of health care).
Entity Name:
Professions for Which
Data Found (No
Action Required):
Professions for Which
Data Requested:
#

Profession Name

We regulate this
profession. (Yes or No)

Were any Actions
taken? (Yes or No)

All Actions are listed in the
Grid below. (Yes or No)

Comments

1

Professon 1

(Yes or No)

(Yes or No)

(Yes or No)

2

Professon 2

(Yes or No)

(Yes or No)

(Yes or No)

3

Professon 3

(Yes or No)

(Yes or No)

(Yes or No)

4

Professon 4

(Yes or No)

(Yes or No)

(Yes or No)

5

Professon 5

(Yes or No)

(Yes or No)

(Yes or No)

6

Professon 6

(Yes or No)

(Yes or No)

(Yes or No)

#

First Name

Last Name

Middle

Suffix

License
Number

Licensure
State

Practitioner Title

Action Type

Action Date Comments/Detail

Example

John

Doe

H

Jr

HA-123A

AK

Nurse Aide

Revocation

1/2/2010

License revoked for failure to comply with terms of
board order XY-1234.

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