State Licensing Board Data Request

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OMS Number: 0906-0081 Expiration Oate: mm/dd/yyyy

Public Burden Statement: The NPOB is a web·based repository of reports containing information on medical malpractice payments and certain adverse actions related to health care practitioners, providers, and suppliers. Established by Congress
in 1986, it is a workforce tool that prevents practitioners from moving state·to-state without disclosure or discovery of previous damaging performance. The statutes and regulations that govern and maintain NPOB operations include: Title IV of

Public Law 99-660, Health Care Quality Improvement Act (HCQIA) of 1986, Section 1921 of the Social Security Act, Section 1128E of the Social Security Act, and Section 6403 of the Patient Protection and Affordable Care Act of 2010. The NPDB

regulations implementing these Jaws are codified at 45 CFR Part 60. An agency may not conduct or sponsor, and a person is not required to respond to,. a collection of information unless it displays a currently valid 0MB control numb-er. The
0MB control number for this information collection is 0906-0081 and it is valid until mm/dd/yyyy. This information collection is voluntary. 45 CFR Section 60.20 provides information on the confidentiality of the NPOB. Information reported to

the NPOBis considered confidential and shall not be disclosed outside of HHS, except as specified in Sections 60.17, 60.18, and 60.21. Public reporting burden for this collection of information is estimated to average 10.5 hours pe-r response,
including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information,
including suggestions for reducing this burden, to HRSA Information Collection Clearance Officer, 5600 Fishers Lane, Room 13N82, Rockville, Maryland, 20857.

Instructions: Please complete the- spreadshe-e-t for all professions listed on the- Compliance Review Summary page-. Include all adverse actions taken during the compliance review period to the National Practitioner Data Bank (NPOB)- refer to
"Reporting State Licensure and Certification Actions" (https://www.npdb.hrsa.gov/resources/aboutGuidebooks.jsp?page-=EStateLicensure-Actions.jsp) in the NPOB Guidebook. If no reportable actions were taken, add the Profession Name and "No

Actions" under Action Type. Save the- completed spreadshe-e-t and upload it on the Compliance Re-view Summary page. We will not accept the data through email because it contains personally identifiable information.
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a First Name

Example

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John

a Last Name

Doe

a Ml

H

a Suffix a License Number a State Issued a Profession Namea Type of Action a Action Datea Comments/Details

Jr

HA-123A

AK

Healthcare
Assistant

Revocation

1/2/2013

License revoked for failure to comply with terms of board
order AK-XY-1234.

a