Authorized Agent Designation

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: 214936

Information Collection (IC) Details

View Information Collection (IC)

Authorized Agent Designation
 
No Modified
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction 34 Authorized Agent Designation.pdf Authorized Agent Designation.pdf Yes Yes Fillable Fileable

Health Consumer Health and Safety

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

183 10
   
State, Local, and Tribal Governments
 
   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 183 0 0 0 0 183
Annual IC Time Burden (Hours) 46 0 0 0 0 46
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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