Document
Hospital Attestation
ICR 202610-0906-006 · OMB 0906-0081 · Object 174170400.
Document Viewer [pdf]
Status: Original and derived artifacts are available for this document.
Download: pdf
Loading document viewer…
Document Metadata
| File Type | application/pdf |
|---|---|
| File Title | Hospital 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
Hospital Attestation Form and Instruction
Non-visible Questions
Label
PDF Name
(step)
Location
Response
Input Item
Visibility Trigger
Why
not?
Hospital
Attestation
(1)
Below the Yes
and No radio
buttons
Text Entry
The field is displayed
if the user selects the
No radio button
Other
State Changes
Label
PDF Name
Item Type
Trigger
OMB Number: 0906- Hospital
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 Profession
Modal
When the user sets Selects the link “+Add
a profession” the modal to add a
profession is displayed and focus is set on
the Search text entry. The user can enter
text in the Search text box to find a
specific profession or select a profession
from the list without searching. The
modal is hidden once the user selects a
profession from the list and the system
adds I or the user selects the Add button.
Hospital
Attestation