Document
Health Center Attestation
ICR 202610-0906-006 · OMB 0906-0081 · Object 174170300.
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Document Metadata
| File Type | application/pdf |
|---|---|
| File Title | Health Center Attestation |
| Last Modified By | Adobe Acrobat (64-bit) 26.1.21431 |
| File Modified | 2026-06-29 |
| File Created | 2026-04-27 |
| Conversion State | complete |
Extracted Text
Health Center Attestation Form and Instruction
Non-visible Questions
Label
PDF Name
(step)
Why
not?
Health Center
Attestation(1)
Location
Response
Input Item
Visibility Trigger
Below the
Text Entry
Yes and No
radio buttons
The field is displayed
if the user selects the
No radio button
Other
State Changes
Label
PDF Name
Item Type
Trigger
OMB Number0906Health Center
0081 Expiration Date: Attestation
mm/dd/yyyy
Modal
When the user selects the link the modal
is displayed with the public burden
statement content.
Add a site
Modal
When the user sets Selects the link “+Add
a site” the page Add a site location is
displayed as a modal. The user can
complete the required form
elements. The modal is hidden once the
user submits the additional site form
information or selects the Cancel button.
Health Center
Attestation