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

Documents and Forms

Document Name Document Type
Form 22 Subject Statement and Dispute Form and Instruction
22 Subject Statement and Dispute.pdf Subject Statement and Dispute.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Subject Statement and Dispute	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

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	22	Subject Statement and Dispute.pdf	Subject Statement and Dispute.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title: System of Record Notice 09-15-0054	FR Citation: 88 FR 17854

Number of Respondents: 4,015	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	4,015	751	3,264
Annual IC Time Burden (Hours)	3,011	563	2,448
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.