41 Health Center Attestation_0915-0126

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

Health Center Attestation_0915-0126

OMB: 0915-0126

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Non-visible Questions
Label
Why
not?

PDF Name
(step)
Health Center
Attestation(1)

Location

Response
Input Item

Below the
Text Entry
Yes and No
radio buttons

Visibility Trigger

Other

The field is displayed
if the user selects the
No radio button

State Changes
Label

PDF Name

Item Type

Trigger

OMB Number: 09150126 Expiration Date:
mm/dd/yyyy

Health Center
Attestation

Modal

When the user selects the link the modal
is displayed with the public burden
statement content.

Add a site

Health Center
Attestation

Modal

When the user sets Selects the link “+Add
a site” the page Add a site location is
displayed as a modal. The user can
complete the required form
elements. The modal is hidden once the
user submits the additional site form
information or selects the Cancel button.


File Typeapplication/pdf
File TitleHealth Center Attestation
SubjectNPDB forms
AuthorHealth Resources and Services Administration
File Modified2020-11-19
File Created2020-08-28

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