Subject Statement and Dispute

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

OMB: 0915-0126

IC ID: 206501

Information Collection (IC) Details

View Information Collection (IC)

Subject Statement and Dispute
 
No Modified
 
Required to Obtain or Retain Benefits
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction 22 Subject Statement and Dispute.pdf Subject Statement and Dispute.pdf Yes Yes Fillable Fileable

Health Consumer Health and Safety

System of Record Notice 09-15-0054  88 FR 17854

4,015 0
   
Individuals or Households
 
   100 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 4,015 0 751 0 0 3,264
Annual IC Time Burden (Hours) 3,011 0 563 0 0 2,448
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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