Form 38 Education Request_0915-0126

Education Request

Privacy Poky

OMB Number: 09·15-0126 Expiration Date: mm/dd/yyyy

Public Burden Statement: The NPDB is a web-based repository of reports containing information on medical malpractice payments and

certain adverse actions related to health care practitioners, providers, and suppliers. Established by Congress in 1986, it is a workforce

tool that prevents practitioners from moving state-to-state without disclosure or discovery of previous damaging performance. The

statutes and regulations that govern and maintain NPDB operations include: Title IV of Public law 9 9-660, Health Care Quality

Improvement Act {HCQIA) of 1986, Section 1921 of the Social Security Act, Section 1128E of the Social Security Act, and Section 6403 of

the Patient Protection and Affordable Care Act of 2010. The NPDB regulations implementing these laws are codified at 45 CFR Part 60.

An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a

currently valid OMB control number. The OMB control number for this information collection is 0915-0126 and it is valid until

XX/XX/202X. This information collection is voluntary. 45 CFR Section 60.20 provides information on the confidentiality of the NPDB.

Information reported to the NPDB is considered confidential and shall not be disclosed outside of HHS, except as specified in Sections

60.17, 60.18, and 60.21. Public reporting burden for this collection of information is estimated to average .08 hours per response,

including the time for reviewing instructions , searching existing data sources, and completing and reviewing the collection of

information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions

for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers lane, Room 14N136B, Rockville, Maryland, 20857 or

[email protected].

Complete the form below to requesl an NPDB staff member to participate in your event. The information you provide will prepopulate an email.
Verify the email is sent to [email protected] and attach the following:
o

Invitation letter on the sponsoring organization's letterhead

o

Draft meeting agenda

For more information, call

301443·2300.

•=Required

Type of Event:

- Select One -

Organization Information

'Name of Sponsoring Organization
Sponsoring organization

'Contact Person
First and last name

'Contact Phone

•contact Email Address
Email

Phone number

Topic Information

'Select a topic of interest:

I

- Select One -

Additional Details or Topics:
Specify what you want to leam

Meeting Location
City

State

r City

I

-- Select One

- ·

Meeting Information
Meeting Title

I

Title

'Meeting Date

'Confirmation Due Date

r

mmlddlyyyy

mmldct.yyyy

Number of Participants

I

'Target Audience

Number of parlic1pants

Target audience

How will you promote attendance (e.g., newsletter, social media)?
How will you promote attendance?

Host Organization (if webinar)

Host organrzat1on

When and in what format do you need the presentation materials to be sent? Please note that we may need up to four weeks
advance notice to prepare these materials.
Submission date and format for presentation materials

Have we presented or hosted an education session for this organization? If so, when?
Have

we

presented or hosted an education session for this orgamzation? If so, when?

Will you publish a recording of our presentation? If so, where will it be published {e.g., on your website)?

I

Ill/here will the pre-recorded presentation be publtshed?

Submit

Note: The Standards of Ethical Conduct forEmployees of the Executive Branch, 5 C.F.R. Part 2635 generally prohibits an employee of an
Executive Branch agency (e.g., HHS)

from accepting

gifts

from outside sources because

of the employee's official position. The Division of

Practitioner Data Bank's (DPDB) speakers may not accept any gift resulting from outreach and educational efforts. Gifts include but are
not limited to cash, meals, gift baskets, speaking fees, travel and lodging.