Health Center Attestation

National Practitioner Data Bank for Adverse Information on Physicians and Other Health Care Practitioners: 45 CFR Part 60 Regulations and Forms

Documents and Forms

Document Name Document Type
Form 41 Health Center Attestation Form and Instruction
41 Health Center Attestation.pdf Health Center Attestation.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Health Center Attestation	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	41	Health Center Attestation.pdf	Health Center Attestation.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title: System of Record Notice 09-15-0054	FR Citation: 88 FR 17854

Number of Respondents: 724	Number of Respondents for Small Entity: 100

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	724	2	722
Annual IC Time Burden (Hours)	724	2	722
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.