Information Collection

Evaluation Survey of Eligible National Practitioner Data Bank (NPDB) Entity Users: Relevance of Information Collected via NPDB Report Forms

IC 266022 under ICR 202306-0915-006 · OMB 0915-0379.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0379 can be found here:

2026-09-23 - Revision of a currently approved collection

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 2 Adverse Action Reports Module Evaluation Survey of Eligible National Practitioner Data Bank (NPDB) Entity Users: Relevance of Information Collected via NPDB Report Forms	Form and Instruction
Form 5 Closing Questions Evaluation Survey of Eligible National Practitioner Data Bank (NPDB) Entity Users: Relevance of Information Collected via NPDB Report Forms	Form and Instruction
Form 4 Judgment or Conviction Reports Module Evaluation Survey of Eligible National Practitioner Data Bank (NPDB) Entity Users: Relevance of Information Collected via NPDB Report Forms	Form and Instruction
Form 3 Medical Malpractice Payment Reports Module Evaluation Survey of Eligible National Practitioner Data Bank (NPDB) Entity Users: Relevance of Information Collected via NPDB Report Forms	Form and Instruction
Form 1 Opening Questions Evaluation Survey of Eligible National Practitioner Data Bank (NPDB) Entity Users: Relevance of Information Collected via NPDB Report Forms	Form and Instruction
Report Survey Intro-Instructions - for OMB Clearance.docx	Instruction
2 Adverse Action Reports Module AAR Questions (2)_V6 - for OMB Clearance.docx	Form and Instruction
5 Closing Questions Closing Questions (5) - All Respondents_V6 - for OMB Clearance.docx	Form and Instruction
4 Judgment or Conviction Reports Module JOCR Questions (4)_V6 - for OMB Clearance.docx	Form and Instruction
3 Medical Malpractice Payment Reports Module MMPR Questions (3)_V6 - for OMB Clearance.docx	Form and Instruction
1 Opening Questions Opening Questions (1) - All Respondents_V6 - for OMB Clearance.docx	Form and Instruction
Introductory eMail_Reports Survey - for OMB Clearance.docx Introductory Email	IC Document
Introductory eMail_Reports Survey - User who received Query Survey - for OMB Clearance.docx Introductory E-mail for Users Who Received Query Survey	IC Document
OMB Fast Track Memo_Infostatica_Request for Approval_Report Survey_Clean.docx Fast Track Memo	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Evaluation Survey of Eligible National Practitioner Data Bank (NPDB) Entity Users: Relevance of Information Collected via NPDB Report Forms

Agency IC Tracking Number:

IC Status: New

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	2	Yes	Yes	Fillable Fileable
Form and Instruction	5	Yes	Yes	Fillable Fileable
Form and Instruction	4	Yes	Yes	Fillable Fileable
Form and Instruction	3	Yes	Yes	Fillable Fileable
Form and Instruction	1	Yes	Yes	Fillable Fileable
Instruction		Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 159

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	159	159
Annual IC Time Burden (Hours)	33	33
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Introductory Email		03/14/2024
Introductory E-mail for Users Who Received Query Survey		03/14/2024
Fast Track Memo		03/14/2024

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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