education request

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Education Request
If you would like an NPOB staff member to participate in an event, please complete the following:

1. Complete the form below.
2. Once completed, this form will prepopulate an email.
3. Verify the email is sent to [email protected] and attach the agenda .
For more information, contact 301-443-2300.

Note: Fields with an asterisk(") are required in order to ensure an accurate response; the information will not be used for any other purpose.

Public Burden Statement
0MB Number. 0906-0081 Expiration Date: mm/dd/yyyy
Public Burden Statement: The NPOB is a web-based repository of re ports containing information on medical m alpractice payments and
certain adverse actions related to health care practitioners, providers, and suppliers. Established by Congress in 1986, it is a wori<force tool
that prevents practitioners from moving state-to-state without disclosure or discovery of previous damaging perform ance. The statutes and
regulations that govern and maintain NPOB operations include: TIiie IV of Public law 99-660, Health Care Quality Improvement Act {HCOIA)
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 NPOB regulations implementing these laws are codified at 45 CFR Part 60. An agency m ay 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 number. The
0MB control number for this information collection is 0906-0081 and it is valid until 1/31 /2027. This information collection is voluntary. 45
CFR Section 60.20 provides information on the confidentiality of the NPDB. Information reported to the NPDB is 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 5 minutes per response, including the time for reviewing instructions, searching existing data sources,
and completing and reviewing the collection of information. Send comm ents 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
l ane, Room 13N82 Rockville, Maryland, 20857.

Choose One:

- Select One --

V

Organization Information
•Name of Sponsoring Organization

I Organization Name
• contact Person

I First and Last Name
• cont act Phone

' Contact Email Addre.ss

I Contact Phone Number

I Contact Email Address

Topic Information
• Select topics of interest:

0 NPDB Overview
A general overvie w of the coltec.ed information. types.of re-ports, rep0rang requirements, disputes,
3nd querying.

0 Report;ng
A detailed explanation of how to report, wha t fo report and when to ('eport. The preseniation ioclude.s
3n interactive discussion ofreporting soonsrios.

0 Querying
A comprehensive review of que,ying that includes eJigibitity, individu-al and bulk enrollment, subject
databases, self-queries. :and query reports.

0 Othe, ( Specify)
Add iti onal Details o r Topics:

Specify in detail the topics you would like to learn about

Meeting Location
Meeting location City

State

I City

- Select One -

Meeting Information
Meeting Title

I Tirle of the Meeting
' Meeting Date

I mm/dd/yyyy
Number of Expected Participants

I

Number of Participants

' Confirmatio n Due Date

0

I mm/ddlyyyy

0

' Target Audience

Target Audience

Host Organization (if webinar)

I Host Organization
By what date, and in what format, wo uld you need presentation materials in advance of the event? Please note that it m ay take up t o four
weeks to have presentations and other materials approved after they are .prepared .

I

Materials need by date

_ _J

Have we previously presented/hosted an education session for th is organization? If so, when?

Have we previously presented/hosted an education session for this organization? If so, when?

-

Note: The Standards of Ethical Conduct for Employees of the Executive B'ranch, 5 C.F.R. Part 2635 generally prohibits an employee of an
Executive Branch agency (e.g. HHS) from accepting gifts (such as cash, meals, gift baskets, and more) from outside sources because of the
employee's official position. Gifts include but are not limited to speaking fees, travel, and lodging. Thus, we advise Iha/ gifts should not be offered to
the Division of Practitioner Data Bank's (DPDB) speakers as a result of DPDB's outreach and educational efforts.