Document
Other Eligible Entity Attestation
ICR 202610-0906-006 · OMB 0906-0081 · Object 174170600.
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Document Metadata
| File Type | application/pdf |
|---|---|
| File Title | Other Eligible Entity Attestation |
| Subject | NPDB Attestation |
| Author | Health Resources and Services Administration |
| Last Modified By | Adobe Acrobat Pro 11.0.23 |
| File Modified | 2023-05-25 |
| File Created | 2023-04-17 |
| Conversion State | complete |
Extracted Text
Other Eligible Entity Attestation Form and Instruction
Non-visible Questions
Label
PDF Name
(step)
Why
not?
Other Eligible
Entity
Attestation (1)
Location
Response
Input Item
Visibility Trigger
Below the Yes Text Entry
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 Number: 09150126 Expiration Date:
mm/dd/yyyy
Other Eligible
Entity
Attestation
Modal
When the user selects the link the modal
is displayed with the public burden
statement content.