National Practitioner Data Bank for Adverse Information on Physicians and Other Health Care Practitioners: 45 CFR Part 60 Regulations and Forms

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 44 Other Eligible Entity Attestation_0915-0126.pdf	Form and Instruction	New	Available
Form 44 Other Eligible Entity Attestation	Form and Instruction	New	Repair queued
Form 43 Medical Malpractice Payer Attestation_0915-0126.pdf	Form and Instruction	New	Available
Form 43 Medical Malpractice Payer, Peer Review Organization, or Private Accreditation Organization Attestation	Form and Instruction	New	Repair queued
Form 42 Hospital Attestation_0915-0126.pdf	Form and Instruction	New	Available
Form 42 Hospital Attestation	Form and Instruction	New	Repair queued
Form 41 Health Center Attestation_0915-0126.pdf	Form and Instruction	New	Available
Form 41 Health Center Attestation	Form and Instruction	New	Repair queued
Form 40 Missing Report from Query_0915-0126.pdf	Form and Instruction	Modified	Available
Form 40 Missing Report from Query Form	Form and Instruction	Modified	Repair queued
Form 39 Account Balance Transfer_0915-0126.pdf	Form and Instruction	Modified	Available
Form 39 Account Balance Transfer	Form and Instruction	Modified	Repair queued
Form 38 Education Request_0915-0126.pdf	Form and Instruction	Modified	Available
Form 38 Education Request	Form and Instruction	Modified	Repair queued
Form 37 Purchase Query Credits_0915-0126.pdf	Form and Instruction	Modified	Available
Form 37 Purchase Query Credits	Form and Instruction	Modified	Repair queued
Form 36 New Administrator Request_0915-0126.pdf	Form and Instruction	Modified	Available
Form 36 New Administrator Request	Form and Instruction	Modified	Repair queued
Form 35 Account Discrepancy_0915-0126.pdf	Form and Instruction	Modified	Available
Form 35 Account Discrepancy	Form and Instruction	Modified	Repair queued
Form 34 Authorized Agent Designation_0915-0126.pdf	Form and Instruction	Modified	Available
Form 34 Authorized Agent Designation	Form and Instruction	Modified	Repair queued
Form 33 Electronic Funds Transfer (EFT) Authorization_0915-0126.pdf	Form and Instruction	Modified	Available
Form 33 Electronic Transfer of Funds (EFT) Authorization	Form and Instruction	Modified	Repair queued
Form 32 Agent Registration (Renewal & Update)_0915-0126.pdf	Form and Instruction	Modified	Available
Form 32 Agent Registration (Renewal & Update)	Form and Instruction	Modified	Repair queued
Form 31 Agent Registration (Initial)_0915-0126.pdf	Form and Instruction	Modified	Available
Form 31 Agent Registration (Initial)	Form and Instruction	Modified	Repair queued
Form 30 Reconciling Missing Actions_0915-0126.pdf	Form and Instruction	Modified	Available
Form 30 Reconciling Missing Actions	Form and Instruction	Modified	Repair queued
Form 29 Corrective Action Plan (Entity)_0915-0126.pdf	Form and Instruction	Modified	Available
Form 29 Corrective Action Plan (Entity)	Form and Instruction	Modified	Repair queued
Form 28 State Licensing Board Attestation_0915-0126.pdf	Form and Instruction	Modified	Available
Form 28 State Licensing Board Attestation	Form and Instruction	Modified	Repair queued
Form 27 State Licensing Board Data Request_0915-0126.pdf	Form and Instruction	Modified	Available
Form 27 State Licensing Board Data Request	Form and Instruction	Modified	Repair queued
Form 26 Authorized Agent Attestation_0915-0126.pdf	Form and Instruction	Modified	Available
Form 26 Authorized Agent Attestation	Form and Instruction	Modified	Repair queued
Form 25 Entity Registration (Renewal & Update)_0915-0126.pdf	Form and Instruction	Modified	Available
Form 25 Entity Registration (Renewal & Update)	Form and Instruction	Modified	Repair queued
Form 24 Entity Registration (Initial)_0915-0126.pdf	Form and Instruction	Modified	Available
Form 24 Entity Registration (Initial)	Form and Instruction	Modified	Repair queued
Form 23 Request for Dispute Resolution_0915-0126.pdf	Form and Instruction	Modified	Available
Form 23 Request for Dispute Resolution	Form and Instruction	Modified	Repair queued
Form 22 Subject Statement and Dispute_0915-0126.pdf	Form and Instruction	Modified	Available
Form 22 Subject Statement and Dispute	Form and Instruction	Modified	Available
Form 21 Continuous Query_0915-0126.pdf	Form and Instruction	Modified	Available
Form 21 Continuous Query	Form and Instruction	Modified	Repair queued
Form 20 Self-Query on an Organization_0916-0126.pdf	Form and Instruction	Modified	Available
Form 20 Self-Query on an Organization	Form and Instruction	Modified	Repair queued
Form 19 Self-Query on an Individual_0915-0126.pdf	Form and Instruction	Modified	Available
Form 19 Self-Query on an Individual	Form and Instruction	Modified	Repair queued
Form 18 One-Time Query for an Organization_0915-0126.pdf	Form and Instruction	Modified	Available
Form 18 One Time Query for an Organization	Form and Instruction	Modified	Available
Form 17 One-Time Query for an Individual_0915-0126.pdf	Form and Instruction	Modified	Available
Form 17 One Time Query for an Individual	Form and Instruction	Modified	Repair queued
Form 16 Health Plan Action_0915-0126.pdf	Form and Instruction	Modified	Available
Form 16 Health Plan Action	Form and Instruction	Modified	Available
Form 15 Government Administrative_0915-0126.pdf	Form and Instruction	Modified	Available
Form 15 Government Administrative	Form and Instruction	Modified	Repair queued
Form 14 Exclusion or Debarment_0915-0126.pdf	Form and Instruction	Modified	Available
Form 14 Exclusion/Debarment	Form and Instruction	Modified	Repair queued
Form 13 Civil Judgment_0915-0126.pdf	Form and Instruction	Modified	Available
Form 13 Civil Judgment	Form and Instruction	Modified	Repair queued
Form 12 Injunction_0915-0126.pdf	Form and Instruction	Modified	Available
Form 12 Injunction	Form and Instruction	Modified	Repair queued
Form 11 Nolo Contendere (no contest plea)_0915-0126.pdf	Form and Instruction	Modified	Available
Form 11 Nolo Contendere (no contest) plea	Form and Instruction	Modified	Repair queued
Form 10 Deferred Conviction or Pre-Trial Diversion_0915-0126.pdf	Form and Instruction	Modified	Available
Form 10 Deferred Conviction or Pre-Trial Diversion	Form and Instruction	Modified	Repair queued
Form 9 Criminal Conviction (Guilty Plea or Trial)_0915-0126.pdf	Form and Instruction	Modified	Available
Form 9 Criminal Conviction (Guilty Plea or Trial)	Form and Instruction	Modified	Repair queued
Form 8 Professional Society_0915-0126.pdf	Form and Instruction	Modified	Available
Form 8 Professional Society	Form and Instruction	Modified	Available
Form 7 Title IV Clinical Privileges Actions_0915-0126.pdf	Form and Instruction	Modified	Available
Form 7 Title IV Clinical Privileges Actions	Form and Instruction	Modified	Repair queued
Form 6 Accreditation Report_0915-0126.pdf	Form and Instruction	Modified	Available
Form 6 Accreditation	Form and Instruction	Modified	Repair queued
Form 5 Peer Review Organization_0915-0126.pdf	Form and Instruction	Modified	Available
Form 5 Peer Review Organization	Form and Instruction	Modified	Repair queued
Form 4 DEA_Federal Licensure_0915-0126.pdf	Form and Instruction	Modified	Available
Form 4 DEA/Federal Licensure	Form and Instruction	Modified	Repair queued
Form 3 State Licensure or Certification_0915-0126.pdf	Form and Instruction	Modified	Available
Form 3 State Licensure	Form and Instruction	Modified	Repair queued
Form 2 Medical Malpractice Payment_0915-0126.pdf	Form and Instruction	Modified	Available
Form 2 Medical Malpractice Payment	Form and Instruction	Modified	Repair queued
Form 1 Correction Revision-to-Action Void Notice of Appeal_0915-0126.pdf	Form and Instruction	Modified	Available
Form 1 Correction, Revision to Action, Correction of Revision to Action, Void, Action on Appeal	Form and Instruction	Modified	Repair queued
NPDB Supporting Statement A 0126.docx	Supporting Statement A	Uploaded 2021-01-22	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
245415	Other Eligible Entity Attestation	Form and Instruction	New	Other Eligible Entity Attestation_0915-0126.pdf
245415	Other Eligible Entity Attestation	Form and Instruction	New
245414	Medical Malpractice Payer, Peer Review Organization, or Private Accreditation Organization Attestation	Form and Instruction	New	Medical Malpractice Payer Attestation_0915-0126.pdf
245414	Medical Malpractice Payer, Peer Review Organization, or Private Accreditation Organization Attestation	Form and Instruction	New
245413	Hospital Attestation	Form and Instruction	New	Hospital Attestation_0915-0126.pdf
245413	Hospital Attestation	Form and Instruction	New
245412	Health Center Attestation	Form and Instruction	New	Health Center Attestation_0915-0126.pdf
245412	Health Center Attestation	Form and Instruction	New
229942	Missing Report from Query Form	Form and Instruction	Modified	Missing Report from Query_0915-0126.pdf
229942	Missing Report from Query Form	Form and Instruction	Modified
229941	Account Balance Transfer	Form and Instruction	Modified	Account Balance Transfer_0915-0126.pdf
229941	Account Balance Transfer	Form and Instruction	Modified
229939	Education Request	Form and Instruction	Modified	Education Request_0915-0126.pdf
229939	Education Request	Form and Instruction	Modified
214939	Purchase Query Credits	Form and Instruction	Modified	Purchase Query Credits_0915-0126.pdf
214939	Purchase Query Credits	Form and Instruction	Modified
214938	New Administrator Request	Form and Instruction	Modified	New Administrator Request_0915-0126.pdf
214938	New Administrator Request	Form and Instruction	Modified
214937	Account Discrepancy	Form and Instruction	Modified	Account Discrepancy_0915-0126.pdf
214937	Account Discrepancy	Form and Instruction	Modified
214936	Authorized Agent Designation	Form and Instruction	Modified	Authorized Agent Designation_0915-0126.pdf
214936	Authorized Agent Designation	Form and Instruction	Modified
214935	Electronic Transfer of Funds (EFT) Authorization	Form and Instruction	Modified	Electronic Funds Transfer (EFT) Authorization_0915-0126.pdf
214935	Electronic Transfer of Funds (EFT) Authorization	Form and Instruction	Modified
214934	Agent Registration (Renewal & Update)	Form and Instruction	Modified	Agent Registration (Renewal & Update)_0915-0126.pdf
214934	Agent Registration (Renewal & Update)	Form and Instruction	Modified
214933	Agent Registration (Initial)	Form and Instruction	Modified	Agent Registration (Initial)_0915-0126.pdf
214933	Agent Registration (Initial)	Form and Instruction	Modified
206509	Reconciling Missing Actions	Form and Instruction	Modified	Reconciling Missing Actions_0915-0126.pdf
206509	Reconciling Missing Actions	Form and Instruction	Modified
206508	Corrective Action Plan (Entity)	Form and Instruction	Modified	Corrective Action Plan (Entity)_0915-0126.pdf
206508	Corrective Action Plan (Entity)	Form and Instruction	Modified
206507	State Licensing Board Attestation	Form and Instruction	Modified	State Licensing Board Attestation_0915-0126.pdf
206507	State Licensing Board Attestation	Form and Instruction	Modified
206506	State Licensing Board Data Request	Form and Instruction	Modified	State Licensing Board Data Request_0915-0126.pdf
206506	State Licensing Board Data Request	Form and Instruction	Modified
206505	Authorized Agent Attestation	Form and Instruction	Modified	Authorized Agent Attestation_0915-0126.pdf
206505	Authorized Agent Attestation	Form and Instruction	Modified
206504	Entity Registration (Renewal & Update)	Form and Instruction	Modified	Entity Registration (Renewal & Update)_0915-0126.pdf
206504	Entity Registration (Renewal & Update)	Form and Instruction	Modified
206503	Entity Registration (Initial)	Form and Instruction	Modified	Entity Registration (Initial)_0915-0126.pdf
206503	Entity Registration (Initial)	Form and Instruction	Modified
206502	Request for Dispute Resolution	Form and Instruction	Modified	Request for Dispute Resolution_0915-0126.pdf
206502	Request for Dispute Resolution	Form and Instruction	Modified
206501	Subject Statement and Dispute	Form and Instruction	Modified	Subject Statement and Dispute_0915-0126.pdf
206501	Subject Statement and Dispute	Form and Instruction	Modified
206500	Continuous Query	Form and Instruction	Modified	Continuous Query_0915-0126.pdf
206500	Continuous Query	Form and Instruction	Modified
206499	Self-Query on an Organization	Form and Instruction	Modified	Self-Query on an Organization_0916-0126.pdf
206499	Self-Query on an Organization	Form and Instruction	Modified
206498	Self-Query on an Individual	Form and Instruction	Modified	Self-Query on an Individual_0915-0126.pdf
206498	Self-Query on an Individual	Form and Instruction	Modified
206497	One Time Query for an Organization	Form and Instruction	Modified	One-Time Query for an Organization_0915-0126.pdf
206497	One Time Query for an Organization	Form and Instruction	Modified
206496	One Time Query for an Individual	Form and Instruction	Modified	One-Time Query for an Individual_0915-0126.pdf
206496	One Time Query for an Individual	Form and Instruction	Modified
206495	Health Plan Action	Form and Instruction	Modified	Health Plan Action_0915-0126.pdf
206495	Health Plan Action	Form and Instruction	Modified
206494	Government Administrative	Form and Instruction	Modified	Government Administrative_0915-0126.pdf
206494	Government Administrative	Form and Instruction	Modified
206493	Exclusion/Debarment	Form and Instruction	Modified	Exclusion or Debarment_0915-0126.pdf
206493	Exclusion/Debarment	Form and Instruction	Modified
206492	Civil Judgment	Form and Instruction	Modified	Civil Judgment_0915-0126.pdf
206492	Civil Judgment	Form and Instruction	Modified
206491	Injunction	Form and Instruction	Modified	Injunction_0915-0126.pdf
206491	Injunction	Form and Instruction	Modified
206490	Nolo Contendere (no contest) plea	Form and Instruction	Modified	Nolo Contendere (no contest plea)_0915-0126.pdf
206490	Nolo Contendere (no contest) plea	Form and Instruction	Modified
206489	Deferred Conviction or Pre-Trial Diversion	Form and Instruction	Modified	Deferred Conviction or Pre-Trial Diversion_0915-0126.pdf
206489	Deferred Conviction or Pre-Trial Diversion	Form and Instruction	Modified
206488	Criminal Conviction (Guilty Plea or Trial)	Form and Instruction	Modified	Criminal Conviction (Guilty Plea or Trial)_0915-0126.pdf
206488	Criminal Conviction (Guilty Plea or Trial)	Form and Instruction	Modified
206487	Professional Society	Form and Instruction	Modified	Professional Society_0915-0126.pdf
206487	Professional Society	Form and Instruction	Modified
206486	Title IV Clinical Privileges Actions	Form and Instruction	Modified	Title IV Clinical Privileges Actions_0915-0126.pdf
206486	Title IV Clinical Privileges Actions	Form and Instruction	Modified
206485	Accreditation	Form and Instruction	Modified	Accreditation Report_0915-0126.pdf
206485	Accreditation	Form and Instruction	Modified
206484	Peer Review Organization	Form and Instruction	Modified	Peer Review Organization_0915-0126.pdf
206484	Peer Review Organization	Form and Instruction	Modified
206483	DEA/Federal Licensure	Form and Instruction	Modified	DEA_Federal Licensure_0915-0126.pdf
206483	DEA/Federal Licensure	Form and Instruction	Modified
206482	State Licensure	Form and Instruction	Modified	State Licensure or Certification_0915-0126.pdf
206482	State Licensure	Form and Instruction	Modified
206481	Medical Malpractice Payment	Form and Instruction	Modified	Medical Malpractice Payment_0915-0126.pdf
206481	Medical Malpractice Payment	Form and Instruction	Modified
206480	Correction, Revision to Action, Correction of Revision to Action, Void, Action on Appeal	Form and Instruction	Modified	Correction Revision-to-Action Void Notice of Appeal_0915-0126.pdf
206480	Correction, Revision to Action, Correction of Revision to Action, Void, Action on Appeal	Form and Instruction	Modified

ICR Details

OMB Control No: 0915-0126	ICR Reference No: 202101-0915-002
Status: Historical Active	Previous ICR Reference No: 201801-0915-001
Agency/Subagency: HHS/HSA	Agency Tracking No: 19186
Title: National Practitioner Data Bank for Adverse Information on Physicians and Other Health Care Practitioners: 45 CFR Part 60 Regulations and Forms
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 04/14/2021
Retrieve Notice of Action (NOA)	Date Received in OIRA: 01/25/2021
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2024	36 Months From Approved	04/30/2021
Responses	7,101,274	0	6,059,761
Time Burden (Hours)	348,368	0	326,120
Cost Burden (Dollars)	0	0	0

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Abstract: The National Practitioner Data Bank (NPDB) is required to receive and release under 45 CFR Part 60 certain adverse data regarding physicians, dentists, and other licensed health care practitioners. Data collected on adverse actions and information relating to the professional competence and conduct of physicians and other health care practitioners will be shared with hospitals, licensing boards, professional societies, and selected health providers. These data will be used to maintain and improve health care and will be obtained from insurers, licensure boards, hospitals, and other providers.

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Authorizing Statute(s): PL: Pub.L. 111 - 148 6403 Name of Law: Patient Protection and Affordable Care Act of 2010
   PL: Pub.L. 104 - 101 221 Name of Law: Establishment of the Health Care Fraud and Abuse Data Collection Program
   PL: Pub.L. 99 - 660 402 Name of Law: Health Care Quality Improvement Act of 1986
   US Code: 42 USC 1320a-7e Name of Law: 3. Section 1128E of the Social Security Act
   US Code: 42 USC 11101 Name of Law: Health Care Quality Improvement Act of 1986
   US Code: 42 USC 1301 Name of Law: Health Care and Abuse Data Collection Program
   US Code: 42 USC 136r-2 Name of Law: 2. Section 1921 of the Social Security Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 65834	10/16/2020
30-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 5220	01/19/2021
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 44

table that charts list of burden

IC Title	Form No.	Form Name
Account Balance Transfer	39	Account Balance Transfer_0915-0126.pdf
Account Discrepancy	35	Account Discrepancy_0915-0126.pdf
Accreditation	6	Accreditation Report_0915-0126.pdf
Agent Registration (Initial)	31	Agent Registration (Initial)_0915-0126.pdf
Agent Registration (Renewal & Update)	32	Agent Registration (Renewal & Update)_0915-0126.pdf
Authorized Agent Attestation	26	Authorized Agent Attestation_0915-0126.pdf
Authorized Agent Designation	34	Authorized Agent Designation_0915-0126.pdf
Civil Judgment	13	Civil Judgment_0915-0126.pdf
Continuous Query	21	Continuous Query_0915-0126.pdf
Correction, Revision to Action, Correction of Revision to Action, Void, Action on Appeal	1	Correction Revision-to-Action Void Notice of Appeal_0915-0126.pdf
Corrective Action Plan (Entity)	29	Corrective Action Plan (Entity)_0915-0126.pdf
Criminal Conviction (Guilty Plea or Trial)	9	Criminal Conviction (Guilty Plea or Trial)_0915-0126.pdf
DEA/Federal Licensure	4	DEA_Federal Licensure_0915-0126.pdf
Deferred Conviction or Pre-Trial Diversion	10	Deferred Conviction or Pre-Trial Diversion_0915-0126.pdf
Education Request	38	Education Request_0915-0126.pdf
Electronic Transfer of Funds (EFT) Authorization	33	Electronic Funds Transfer (EFT) Authorization_0915-0126.pdf
Entity Registration (Initial)	24	Entity Registration (Initial)_0915-0126.pdf
Entity Registration (Renewal & Update)	25	Entity Registration (Renewal & Update)_0915-0126.pdf
Exclusion/Debarment	14	Exclusion or Debarment_0915-0126.pdf
Government Administrative	15	Government Administrative_0915-0126.pdf
Health Center Attestation	41	Health Center Attestation_0915-0126.pdf
Health Plan Action	16	Health Plan Action_0915-0126.pdf
Hospital Attestation	42	Hospital Attestation_0915-0126.pdf
Injunction	12	Injunction_0915-0126.pdf
Medical Malpractice Payer, Peer Review Organization, or Private Accreditation Organization Attestation	43	Medical Malpractice Payer Attestation_0915-0126.pdf
Medical Malpractice Payment	2	Medical Malpractice Payment_0915-0126.pdf
Missing Report from Query Form	40	Missing Report from Query_0915-0126.pdf
New Administrator Request	36	New Administrator Request_0915-0126.pdf
Nolo Contendere (no contest) plea	11	Nolo Contendere (no contest plea)_0915-0126.pdf
One Time Query for an Individual	17	One-Time Query for an Individual_0915-0126.pdf
One Time Query for an Organization	18	One-Time Query for an Organization_0915-0126.pdf
Other Eligible Entity Attestation	44	Other Eligible Entity Attestation_0915-0126.pdf
Peer Review Organization	5	Peer Review Organization_0915-0126.pdf
Professional Society	8	Professional Society_0915-0126.pdf
Purchase Query Credits	37	Purchase Query Credits_0915-0126.pdf
Reconciling Missing Actions	30	Reconciling Missing Actions_0915-0126.pdf
Request for Dispute Resolution	23	Request for Dispute Resolution_0915-0126.pdf
Self-Query on an Individual	19	Self-Query on an Individual_0915-0126.pdf
Self-Query on an Organization	20	Self-Query on an Organization_0916-0126.pdf
State Licensing Board Attestation	28	State Licensing Board Attestation_0915-0126.pdf
State Licensing Board Data Request	27	State Licensing Board Data Request_0915-0126.pdf
State Licensure	3	State Licensure or Certification_0915-0126.pdf
Subject Statement and Dispute	22	Subject Statement and Dispute_0915-0126.pdf
Title IV Clinical Privileges Actions	7	Title IV Clinical Privileges Actions_0915-0126.pdf

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	7,101,274	6,059,761	0	1,041,513	0	0
Annual Time Burden (Hours)	348,368	326,120	0	22,248	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: The number of respondents have increased or decreased for some forms causing the increase or decrease in burden.

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Annual Cost to Federal Government: $19,100,000

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Yes

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 01/25/2021

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