State Licensing Board Data Request

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

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0126 can be found here:

Documents and Forms

Document Name Document Type
Form 27 State Licensing Board Data Request Form and Instruction
27 State Licensing Board Data Request_0915-0126.pdf State Licensing Board Data Request_0915-0126.pdf Form and Instruction
27 State Licensing Board Data Request_0915-0126.pdf State Licensing Board Data Request_0915-0126.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	State Licensing Board Data Request	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	27	State Licensing Board Data Request_0915-0126.pdf	State Licensing Board Data Request_0915-0126.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 60	Number of Respondents for Small Entity: 25

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	60	-86	146
Annual IC Time Burden (Hours)	630	-903	1,533
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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.