Information Collection

National Practitioner Data Bank (NPDB) Attestation of Reports by Hospitals, Medical Malpractice Payers, Health Plans, and Certain Other Health Care Entities

IC 224198 under ICR 202004-0906-001 · OMB 0906-0028.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Form - Agent Attestation.pdf National Practitioner Data Bank (NPDB) Attestation of Reports by Hospitals, Medical Malpractice Payers, Health Plans, and Certain Other Health Care Entities	Form and Instruction
Form 2 Form - Health Center Attestation and Add Site.pdf National Practitioner Data Bank (NPDB) Attestation of Reports by Hospitals, Medical Malpractice Payers, Health Plans, and Certain Other Health Care Entities	Form and Instruction
Form 3 Form - Hospital Attestation.pdf National Practitioner Data Bank (NPDB) Attestation of Reports by Hospitals, Medical Malpractice Payers, Health Plans, and Certain Other Health Care Entities	Form and Instruction
Form 4 Form - Medical Malpractice Payer Attestation.pdf National Practitioner Data Bank (NPDB) Attestation of Reports by Hospitals, Medical Malpractice Payers, Health Plans, and Certain Other Health Care Entities	Form and Instruction
Form 5 Form - Other Eligible Entity Attestation.pdf National Practitioner Data Bank (NPDB) Attestation of Reports by Hospitals, Medical Malpractice Payers, Health Plans, and Certain Other Health Care Entities	Form and Instruction
1 Form - Agent Attestation.pdf Form - Agent Attestation.pdf	Form and Instruction
2 Form - Health Center Attestation and Add Site.pdf Form - Health Center Attestation and Add Site.pdf	Form and Instruction
3 Form - Hospital Attestation.pdf Form - Hospital Attestation.pdf	Form and Instruction
4 Form - Medical Malpractice Payer Attestation.pdf Form - Medical Malpractice Payer Attestation.pdf	Form and Instruction
5 Form - Other Eligible Entity Attestation.pdf Form - Other Eligible Entity Attestation.pdf	Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

National Practitioner Data Bank (NPDB) Attestation of Reports by Hospitals, Medical Malpractice Payers, Health Plans, and Certain Other Health Care Entities

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1	Yes	Yes	Fillable Fileable
Form and Instruction	2	Yes	Yes	Fillable Fileable
Form and Instruction	3	Yes	Yes	Fillable Fileable
Form and Instruction	4	Yes	Yes	Fillable Fileable
Form and Instruction	5	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 11,600

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	11,600	4,865	6,735
Annual IC Time Burden (Hours)	11,600	4,865	6,735
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
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.

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